Healthcare Provider Details

I. General information

NPI: 1588944045
Provider Name (Legal Business Name): ALTON DELANA DYKES V RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2011
Last Update Date: 08/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 BROAD ST
HAWKINSVILLE GA
31036-4815
US

IV. Provider business mailing address

126 BROAD ST
HAWKINSVILLE GA
31036-4815
US

V. Phone/Fax

Practice location:
  • Phone: 478-783-4700
  • Fax: 478-783-4706
Mailing address:
  • Phone: 478-783-2325
  • Fax: 478-783-4706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH009241
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: