Provider Demographics
NPI:1972083327
Name:AVERY, MARK J
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:AVERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N 5TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-2704
Mailing Address - Country:US
Mailing Address - Phone:706-291-0999
Mailing Address - Fax:706-291-2558
Practice Address - Street 1:710 N 5TH AVE NE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-2704
Practice Address - Country:US
Practice Address - Phone:706-291-0999
Practice Address - Fax:706-291-2558
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA013593183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician