Provider Demographics
NPI:1295025484
Name:SWANSON, MONA KIM (RPH)
Entity type:Individual
Prefix:
First Name:MONA
Middle Name:KIM
Last Name:SWANSON
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 1:650 E WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:GA
Mailing Address - Zip Code:31714-5316
Mailing Address - Country:US
Mailing Address - Phone:229-567-3007
Mailing Address - Fax:229-567-0473
Practice Address - Street 1:650 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:GA
Practice Address - Zip Code:31714-5316
Practice Address - Country:US
Practice Address - Phone:229-567-3007
Practice Address - Fax:229-567-0473
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-09
Last Update Date:2011-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA18050183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist