Provider Demographics
NPI:1831261387
Name:TALLEY, PHILLIP DAVID
Entity type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:DAVID
Last Name:TALLEY
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 1:114 COVE RD
Mailing Address - Street 2:
Mailing Address - City:CHICKAMAUGA
Mailing Address - State:GA
Mailing Address - Zip Code:30707-1407
Mailing Address - Country:US
Mailing Address - Phone:706-375-2611
Mailing Address - Fax:706-375-6219
Practice Address - Street 1:114 COVE RD
Practice Address - Street 2:
Practice Address - City:CHICKAMAUGA
Practice Address - State:GA
Practice Address - Zip Code:30707-1407
Practice Address - Country:US
Practice Address - Phone:706-375-2611
Practice Address - Fax:706-375-6219
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010992183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist