Provider Demographics
NPI:1801134069
Name:MORTIMER, PATRICIA DIANE (RPH)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:DIANE
Last Name:MORTIMER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:DIANE
Other - Last Name:COGGINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:120 PROMINENCE POINT PKWY
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-9008
Mailing Address - Country:US
Mailing Address - Phone:770-720-4825
Mailing Address - Fax:770-720-4503
Practice Address - Street 1:101 PROMINENCE POINT PKWY
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-9009
Practice Address - Country:US
Practice Address - Phone:770-704-4045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-23
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014397183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist