Healthcare Provider Details

I. General information

NPI: 1164739918
Provider Name (Legal Business Name): ROBERT ERVIN EVERETT JR. RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2010
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1918 RAILROAD ST
STATHAM GA
30666-1875
US

IV. Provider business mailing address

PO BOX 367 1050 CLOTFELTER LN
BOGART GA
30622-0367
US

V. Phone/Fax

Practice location:
  • Phone: 706-725-1122
  • Fax:
Mailing address:
  • Phone: 706-338-7657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH013637
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: