Healthcare Provider Details

I. General information

NPI: 1184031577
Provider Name (Legal Business Name): JAMES LEE DYKES PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 07/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 N OAK STREET EXT
VALDOSTA GA
31605-6473
US

IV. Provider business mailing address

3200 N OAK STREET EXT
VALDOSTA GA
31605-6473
US

V. Phone/Fax

Practice location:
  • Phone: 229-247-2553
  • Fax:
Mailing address:
  • Phone: 229-247-2553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number027985
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: