Provider Demographics
NPI:1255742136
Name:BAILEY, ELISABETH JOHNSON (RPH)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:JOHNSON
Last Name:BAILEY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2818 WICKEFORD MILL DR
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-7611
Mailing Address - Country:US
Mailing Address - Phone:678-622-3766
Mailing Address - Fax:
Practice Address - Street 1:400 SHALLOWFORD RD NW
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30504-4152
Practice Address - Country:US
Practice Address - Phone:770-531-0325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH018859183500000X
SC8882183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH018859OtherPHARMACY LICENSE NUMBER FOR THE STATE OF GEORGIA