Provider Demographics
NPI:1982331393
Name:MILLWOOD, AUSTIN DAVID
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:DAVID
Last Name:MILLWOOD
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 1:510 GA HIGHWAY 247 S
Mailing Address - Street 2:
Mailing Address - City:BONAIRE
Mailing Address - State:GA
Mailing Address - Zip Code:31005-3865
Mailing Address - Country:US
Mailing Address - Phone:478-273-6163
Mailing Address - Fax:478-246-0205
Practice Address - Street 1:510 GA HIGHWAY 247 S
Practice Address - Street 2:
Practice Address - City:BONAIRE
Practice Address - State:GA
Practice Address - Zip Code:31005-3865
Practice Address - Country:US
Practice Address - Phone:478-662-2987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH033818183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH033818Medicaid