Provider Demographics
NPI:1598646846
Name:REVELS, NATHAN
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:REVELS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 VIRGINIA AVE N
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-4227
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:620 VIRGINIA AVE N
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-4227
Practice Address - Country:US
Practice Address - Phone:229-386-1166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-11
Last Update Date:2025-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH035837183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist