Provider Demographics
NPI:1134171051
Name:WYNN, CHARLES HUBERT (RPH)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:HUBERT
Last Name:WYNN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S 6TH STREET EXT
Mailing Address - Street 2:
Mailing Address - City:MILNER
Mailing Address - State:GA
Mailing Address - Zip Code:30257-3026
Mailing Address - Country:US
Mailing Address - Phone:770-228-3907
Mailing Address - Fax:770-229-4078
Practice Address - Street 1:566 S 8TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4212
Practice Address - Country:US
Practice Address - Phone:770-227-9432
Practice Address - Fax:770-229-4078
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9650183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist