Healthcare Provider Details

I. General information

NPI: 1255053534
Provider Name (Legal Business Name): BRENT THOMAS PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 GA HIGHWAY 21
PORT WENTWORTH GA
31407-9205
US

IV. Provider business mailing address

7300 GA HIGHWAY 21
PORT WENTWORTH GA
31407-9205
US

V. Phone/Fax

Practice location:
  • Phone: 912-964-1797
  • Fax:
Mailing address:
  • Phone: 912-964-1797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH033836
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: