Provider Demographics
NPI:1336621010
Name:REVELS, CARRIE SHAE (PHARMD)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:SHAE
Last Name:REVELS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 HIGHWAY 37
Mailing Address - Street 2:
Mailing Address - City:ADEL
Mailing Address - State:GA
Mailing Address - Zip Code:31620-8650
Mailing Address - Country:US
Mailing Address - Phone:229-237-4345
Mailing Address - Fax:
Practice Address - Street 1:3330 INNER PERIMETER RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-7063
Practice Address - Country:US
Practice Address - Phone:229-671-9840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030895183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist