Healthcare Provider Details

I. General information

NPI: 1902177868
Provider Name (Legal Business Name): TERESA HOLDER ASTIN RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2012
Last Update Date: 01/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 S MARBLE ST
ROCKMART GA
30153-2642
US

IV. Provider business mailing address

114 S MARBLE ST
ROCKMART GA
30153-2642
US

V. Phone/Fax

Practice location:
  • Phone: 770-684-6573
  • Fax: 770-684-4553
Mailing address:
  • Phone: 770-684-6573
  • Fax: 770-684-4553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH14580
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: