=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265561302
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONNETTA L HEROLD RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 465 N BELAIR RD SUITE 1A
-----------------------------------------------------
City | EVANS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30809-3188
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-854-2424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4306 COLONY SQ
-----------------------------------------------------
City | EVANS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30809-4298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-868-9143
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 4993
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 17157
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------