Provider Demographics
NPI:1245340041
Name:WATERS, JOHN ROLAND (RPH)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ROLAND
Last Name:WATERS
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 1:624 OLD PLANTATION RD
Mailing Address - Street 2:
Mailing Address - City:JEKYLL ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31527-0724
Mailing Address - Country:US
Mailing Address - Phone:912-635-3188
Mailing Address - Fax:
Practice Address - Street 1:10 N BEACHVIEW DR
Practice Address - Street 2:
Practice Address - City:JEKYLL ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31527-0816
Practice Address - Country:US
Practice Address - Phone:912-635-2246
Practice Address - Fax:912-635-2100
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9593183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA9593OtherPHARMACIST