Provider Demographics
NPI:1942580493
Name:GEORGE, GAYNELL WILLIAMS (RPH)
Entity Type:Individual
Prefix:
First Name:GAYNELL
Middle Name:WILLIAMS
Last Name:GEORGE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:GAYNELL
Other - Middle Name:JEAN
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:5147 LAKECOVE CT
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-7656
Mailing Address - Country:US
Mailing Address - Phone:504-621-9774
Mailing Address - Fax:678-391-2851
Practice Address - Street 1:9465 HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1509
Practice Address - Country:US
Practice Address - Phone:678-715-8494
Practice Address - Fax:678-715-8504
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-27
Last Update Date:2011-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH022934183500000X
LA13480183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist