Provider Demographics
NPI:1700480704
Name:HURST, CHARLES ANTHONY
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ANTHONY
Last Name:HURST
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 1:12 DECATUR ST
Mailing Address - Street 2:
Mailing Address - City:CHATTAHOOCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:32324-1099
Mailing Address - Country:US
Mailing Address - Phone:850-663-2268
Mailing Address - Fax:850-663-3923
Practice Address - Street 1:12 DECATUR ST
Practice Address - Street 2:
Practice Address - City:CHATTAHOOCHEE
Practice Address - State:FL
Practice Address - Zip Code:32324-1099
Practice Address - Country:US
Practice Address - Phone:850-663-2268
Practice Address - Fax:850-663-3923
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0028537183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist