Provider Demographics
NPI:1265703128
Name:PROVOST, DETRA ELAINE (RPH)
Entity type:Individual
Prefix:MRS
First Name:DETRA
Middle Name:ELAINE
Last Name:PROVOST
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MRS
Other - First Name:DETRA
Other - Middle Name:ELAINE
Other - Last Name:WOOTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:114 ABERDEEN DR
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-7100
Mailing Address - Country:US
Mailing Address - Phone:803-649-3603
Mailing Address - Fax:803-649-3603
Practice Address - Street 1:4223 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3069
Practice Address - Country:US
Practice Address - Phone:706-869-0937
Practice Address - Fax:706-993-9781
Is Sole Proprietor?:No
Enumeration Date:2012-01-24
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH18214183500000X
SC8706183500000X
TX32754183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist