Provider Demographics
NPI:1396940136
Name:PAYNE, LORI JACKSON (RPH)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:JACKSON
Last Name:PAYNE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1872 PAYNE POND RD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:GA
Mailing Address - Zip Code:31832-3136
Mailing Address - Country:US
Mailing Address - Phone:229-942-1643
Mailing Address - Fax:229-828-2140
Practice Address - Street 1:100 WHEATLEY DR
Practice Address - Street 2:
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-3788
Practice Address - Country:US
Practice Address - Phone:229-931-1265
Practice Address - Fax:229-931-1175
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA19085183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist