Healthcare Provider Details

I. General information

NPI: 1093304933
Provider Name (Legal Business Name): MADISON J LEDFORD RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2021
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 N MAIN ST
LA FAYETTE GA
30728-2150
US

IV. Provider business mailing address

1201 N MAIN ST
LA FAYETTE GA
30728-2150
US

V. Phone/Fax

Practice location:
  • Phone: 706-638-1281
  • Fax: 706-638-1283
Mailing address:
  • Phone: 706-638-1281
  • Fax: 706-638-1283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH015224
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: