Healthcare Provider Details

I. General information

NPI: 1134100613
Provider Name (Legal Business Name): JOHN B CARROLL III RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 QUAIL TRL
AMERICUS GA
31709-9289
US

IV. Provider business mailing address

181 QUAIL TRL
AMERICUS GA
31709-9289
US

V. Phone/Fax

Practice location:
  • Phone: 229-924-9352
  • Fax: 229-931-5956
Mailing address:
  • Phone: 229-924-9352
  • Fax: 229-931-5956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number15701
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: