Healthcare Provider Details

I. General information

NPI: 1720687387
Provider Name (Legal Business Name): JESSICA LATHAM PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 10/23/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S LEROY ST
METTER GA
30439-4631
US

IV. Provider business mailing address

209 BOYD DR
RICHMOND HILL GA
31324-4160
US

V. Phone/Fax

Practice location:
  • Phone: 912-685-2803
  • Fax:
Mailing address:
  • Phone: 912-660-8590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number239126
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number032314
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: