Provider Demographics
NPI:1952998163
Name:MIZELLE, JOSHUA TIMOTHY
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:TIMOTHY
Last Name:MIZELLE
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:PO BOX 2698
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-2698
Mailing Address - Country:US
Mailing Address - Phone:912-489-7979
Mailing Address - Fax:912-489-6744
Practice Address - Street 1:4439 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-9188
Practice Address - Country:US
Practice Address - Phone:912-489-7979
Practice Address - Fax:912-489-6744
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH025110183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist