Provider Demographics
NPI:1669074522
Name:THOMPSON, MAVERISA VILLANUEVA (RPH)
Entity type:Individual
Prefix:
First Name:MAVERISA
Middle Name:VILLANUEVA
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6608 BLUE COVE DR
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-0056
Mailing Address - Country:US
Mailing Address - Phone:678-770-2707
Mailing Address - Fax:
Practice Address - Street 1:3795 BUFORD DR
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-4906
Practice Address - Country:US
Practice Address - Phone:770-271-9807
Practice Address - Fax:770-271-9809
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-14
Last Update Date:2020-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017095183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist