Provider Demographics
NPI:1477144301
Name:CUNNINGHAM, JASON LAMAR
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:LAMAR
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JASON
Other - Middle Name:LAMAR
Other - Last Name:CUNNINGHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CPHT
Mailing Address - Street 1:703 NORTH VETERANS BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENNVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30427
Mailing Address - Country:US
Mailing Address - Phone:912-654-3031
Mailing Address - Fax:912-654-1779
Practice Address - Street 1:703 N VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:GLENNVILLE
Practice Address - State:GA
Practice Address - Zip Code:30427-2208
Practice Address - Country:US
Practice Address - Phone:912-654-3031
Practice Address - Fax:912-654-1779
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2024-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA380101061157017183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA3801-0106-1157-017OtherCPHT CERT. #