=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124398540
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN WAYNE GEORGE PHARM D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2012
-----------------------------------------------------
Last Update Date | 01/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2513 S STATE HIGHWAY 36
-----------------------------------------------------
City | GATESVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76528-2519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-865-2417
-----------------------------------------------------
Fax | 254-865-4024
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2513 S STATE HIGHWAY 36
-----------------------------------------------------
City | GATESVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76528-2519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-865-2417
-----------------------------------------------------
Fax | 254-865-4024
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 34773
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------