Healthcare Provider Details

I. General information

NPI: 1548256514
Provider Name (Legal Business Name): TOMMY P PORTER R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: TOMMY PORTER

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 N 2ND ST
COCHRAN GA
31014-8742
US

IV. Provider business mailing address

129 N 2ND ST
COCHRAN GA
31014-8742
US

V. Phone/Fax

Practice location:
  • Phone: 478-934-6344
  • Fax: 478-934-8820
Mailing address:
  • Phone: 478-934-6344
  • Fax: 478-934-8820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number012215
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: