Healthcare Provider Details

I. General information

NPI: 1346348653
Provider Name (Legal Business Name): JACK HAROLD MILLS SR. R.PH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 N WILEY AVE
DONALSONVILLE GA
39845-1121
US

IV. Provider business mailing address

PO BOX 232 5111 MILLS RD.
DONALSONVILLE GA
39845-0232
US

V. Phone/Fax

Practice location:
  • Phone: 229-524-2313
  • Fax: 229-524-1202
Mailing address:
  • Phone: 229-524-2313
  • Fax: 229-524-1202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number009642
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: