Provider Demographics
NPI:1740965094
Name:HARDESTY, MITCHELL (CPHT)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:HARDESTY
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-1748
Mailing Address - Country:US
Mailing Address - Phone:770-905-1855
Mailing Address - Fax:
Practice Address - Street 1:780 GLYNN ST N
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1193
Practice Address - Country:US
Practice Address - Phone:770-716-2262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHTC038176183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician