Provider Demographics
NPI:1649870718
Name:BASSETT, PETER BRADLEY
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:BRADLEY
Last Name:BASSETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 TRAIL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31757-1814
Mailing Address - Country:US
Mailing Address - Phone:229-403-7447
Mailing Address - Fax:
Practice Address - Street 1:361 8TH AVE NE
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:GA
Practice Address - Zip Code:39828-1603
Practice Address - Country:US
Practice Address - Phone:229-377-1451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH796347183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist