Provider Demographics
NPI:1780770222
Name:PURVIS, FRED EUGENE (GA RPH 10245)
Entity type:Individual
Prefix:MR
First Name:FRED
Middle Name:EUGENE
Last Name:PURVIS
Suffix:
Gender:M
Credentials:GA RPH 10245
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 HWY 37
Mailing Address - Street 2:
Mailing Address - City:ADEL
Mailing Address - State:GA
Mailing Address - Zip Code:31620
Mailing Address - Country:US
Mailing Address - Phone:229-896-2637
Mailing Address - Fax:229-896-1302
Practice Address - Street 1:WINN DIXIE 101
Practice Address - Street 2:103 TALMADGE DR
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768
Practice Address - Country:US
Practice Address - Phone:229-891-2555
Practice Address - Fax:229-890-9826
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGARPH10295183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist