Healthcare Provider Details

I. General information

NPI: 1417230244
Provider Name (Legal Business Name): TOM MAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2011
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 WASHINGTON RD
MARTINEZ GA
30907-2322
US

IV. Provider business mailing address

139 ADAMS LAKE CT
LAWRENCEVILLE GA
30046-5322
US

V. Phone/Fax

Practice location:
  • Phone: 706-868-8084
  • Fax:
Mailing address:
  • Phone: 770-237-9875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH018780
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: