Healthcare Provider Details

I. General information

NPI: 1790290443
Provider Name (Legal Business Name): MARY CATHERINE FERGUSON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2017
Last Update Date: 12/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12240 AUGUSTA RD
LAVONIA GA
30553-1210
US

IV. Provider business mailing address

PO BOX 184
BOWERSVILLE GA
30516-0184
US

V. Phone/Fax

Practice location:
  • Phone: 706-356-8863
  • Fax:
Mailing address:
  • Phone: 706-599-3926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRPH029929
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: