Healthcare Provider Details

I. General information

NPI: 1124014592
Provider Name (Legal Business Name): WILLIE EVERETT STILL JR. R. PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 CAMERONS WAY
COVINGTON GA
30016-1160
US

IV. Provider business mailing address

40 CAMERONS WAY
COVINGTON GA
30016-1160
US

V. Phone/Fax

Practice location:
  • Phone: 678-232-5665
  • Fax:
Mailing address:
  • Phone: 678-232-5665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10595
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: