Healthcare Provider Details

I. General information

NPI: 1700480704
Provider Name (Legal Business Name): CHARLES ANTHONY HURST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 DECATUR ST
CHATTAHOOCHEE FL
32324-1099
US

IV. Provider business mailing address

12 DECATUR ST
CHATTAHOOCHEE FL
32324-1099
US

V. Phone/Fax

Practice location:
  • Phone: 850-663-2268
  • Fax: 850-663-3923
Mailing address:
  • Phone: 850-663-2268
  • Fax: 850-663-3923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS0028537
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: