Provider Demographics
NPI:1881759546
Name:NELSON, ROBERT MARION (RPH)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:MARION
Last Name:NELSON
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 1:112 S 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MC RAE
Mailing Address - State:GA
Mailing Address - Zip Code:31055-1539
Mailing Address - Country:US
Mailing Address - Phone:229-868-6735
Mailing Address - Fax:229-868-2611
Practice Address - Street 1:112 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:MC RAE
Practice Address - State:GA
Practice Address - Zip Code:31055-1539
Practice Address - Country:US
Practice Address - Phone:229-868-6735
Practice Address - Fax:229-868-2611
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-23
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003298183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1155360001Medicare NSC