Healthcare Provider Details

I. General information

NPI: 1982207049
Provider Name (Legal Business Name): MR. CLIFFORD STEWART HURST I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2020
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 HIGHWAY 42 N
MCDONOUGH GA
30253-4301
US

IV. Provider business mailing address

2720 HIGHWAY 42 N
MCDONOUGH GA
30253-4301
US

V. Phone/Fax

Practice location:
  • Phone: 678-432-9450
  • Fax: 678-432-3029
Mailing address:
  • Phone: 678-432-9450
  • Fax: 678-432-3029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH022711
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: