Provider Demographics
NPI:1982941654
Name:HEATH, CALVIN HOMER JR
Entity Type:Individual
Prefix:
First Name:CALVIN
Middle Name:HOMER
Last Name:HEATH
Suffix:JR
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 1:5435 WOODRUFF FARM RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-1395
Mailing Address - Country:US
Mailing Address - Phone:706-568-8826
Mailing Address - Fax:
Practice Address - Street 1:5435 WOODRUFF FARM RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-1395
Practice Address - Country:US
Practice Address - Phone:706-568-8826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA013645183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist