Healthcare Provider Details

I. General information

NPI: 1790992154
Provider Name (Legal Business Name): JETT LAVERN MCCULLOUGH PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 W HILL ST
THOMSON GA
30824-2116
US

IV. Provider business mailing address

PO BOX 381 41 CRESTVIEW AVE
WARRENTON GA
30828-0381
US

V. Phone/Fax

Practice location:
  • Phone: 706-595-4842
  • Fax: 706-595-8665
Mailing address:
  • Phone: 706-465-9209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number13447
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: