Healthcare Provider Details

I. General information

NPI: 1790511368
Provider Name (Legal Business Name): NAPHUN NIMMANONDA PHARMD
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 LANEY WALKER BLVD # AD1400
AUGUSTA GA
30912-0002
US

IV. Provider business mailing address

37 CHARLESTOWNE DR
AUGUSTA GA
30907-3863
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-4815
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH031499
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: