Provider Demographics
NPI:1770602310
Name:BROCK, WINSTON B (RPH)
Entity type:Individual
Prefix:DR
First Name:WINSTON
Middle Name:B
Last Name:BROCK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 E SHOTWELL ST
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-4237
Mailing Address - Country:US
Mailing Address - Phone:229-246-1000
Mailing Address - Fax:229-246-5643
Practice Address - Street 1:1205 E SHOTWELL ST
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-4237
Practice Address - Country:US
Practice Address - Phone:229-246-1000
Practice Address - Fax:229-246-5643
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE006828183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA55003547AMedicaid
GA55003547AMedicaid