Healthcare Provider Details

I. General information

NPI: 1376825091
Provider Name (Legal Business Name): REBECCA BUTTS FORT PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2011
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4808 BUENA VISTA RD
COLUMBUS GA
31907-5014
US

IV. Provider business mailing address

4808 BUENA VISTA RD
COLUMBUS GA
31907-5014
US

V. Phone/Fax

Practice location:
  • Phone: 706-569-9439
  • Fax:
Mailing address:
  • Phone: 706-569-9439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH023098
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: