=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659619757
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES RUSSELL HANDBERRY JR. RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2013
-----------------------------------------------------
Last Update Date | 01/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 840 GLYNN ST S
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30214-2031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-817-5420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 SPIDER LILY CT
-----------------------------------------------------
City | GRIFFIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30223-5883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-273-4848
-----------------------------------------------------
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 | 010206
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------