Healthcare Provider Details

I. General information

NPI: 1407857303
Provider Name (Legal Business Name): MARCIA WILLIS BROCK PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E SHOTWELL ST
BAINBRIDGE GA
39819-4256
US

IV. Provider business mailing address

3077 FOWLSTOWN RD
BAINBRIDGE GA
39819-6632
US

V. Phone/Fax

Practice location:
  • Phone: 229-243-6163
  • Fax: 229-243-3327
Mailing address:
  • Phone: 229-243-6163
  • Fax: 229-243-3327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number018452
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: