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1265703128 NPI number — DETRA ELAINE PROVOST RPH

NPI Number: 1265703128
Health Care Provider/Practitioner: DETRA ELAINE PROVOST RPH

Information about “1265703128” NPI (DETRA ELAINE PROVOST RPH) exists in 1265703128 in HTML format HTML  |  1265703128 in plain Text format TXT  |  1265703128 in PDF (Portable Document Format) PDF  |  1265703128 in an XML format XML  formats.

NPI Number : 1265703128 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1265703128",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "PROVOST",
    "FirstName": "DETRA",
    "MiddleName": "ELAINE",
    "NamePrefix": "MRS.",
    "NameSuffix": null,
    "Credential": "RPH",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": "WOOTEN",
    "OtherFirstName": "DETRA",
    "OtherMiddleName": "ELAINE",
    "OtherNamePrefix": "MRS.",
    "OtherNameSuffix": null,
    "OtherCredential": "RPH",
    "OtherLastNameTypeCode": "1",
    "FirstLineMailingAddress": "114 ABERDEEN DR",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "AIKEN",
    "MailingAddressStateName": "SC",
    "MailingAddressPostalCode": "29803-7100",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "803-649-3603",
    "MailingAddressFaxNumber": "803-649-3603",
    "FirstLinePracticeLocationAddress": "4223 WASHINGTON RD",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "EVANS",
    "PracticeLocationAddressStateName": "GA",
    "PracticeLocationAddressPostalCode": "30809-3069",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "706-869-0937",
    "PracticeLocationAddressFaxNumber": "706-993-9781",
    "EnumerationDate": "01/24/2012",
    "LastUpdateDate": "01/24/2012",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "183500000X",
          "TaxonomyName": "Pharmacist",
          "LicenseNumber": "RPH18214",
          "LicenseNumberStateCode": "GA",
          "PrimaryTaxonomySwitch": "Y"
        },
        {
          "TaxonomyCode": "183500000X",
          "TaxonomyName": "Pharmacist",
          "LicenseNumber": "8706",
          "LicenseNumberStateCode": "SC",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "183500000X",
          "TaxonomyName": "Pharmacist",
          "LicenseNumber": "32754",
          "LicenseNumberStateCode": "TX",
          "PrimaryTaxonomySwitch": "N"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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