=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548690423
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARRY ETHRIDGE R.PH.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2013
-----------------------------------------------------
Last Update Date | 11/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4240 LUTHER WARD RD
-----------------------------------------------------
City | POWDER SPRINGS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30127-1184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-726-9837
-----------------------------------------------------
Fax | 770-726-9837
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4240 LUTHER WARD RD
-----------------------------------------------------
City | POWDER SPRINGS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30127-1184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-726-9837
-----------------------------------------------------
Fax | 770-726-9837
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RPH010737
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------