=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740488600
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL BRANDON GRIFFIN PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 TALMADGE DR
-----------------------------------------------------
City | MOULTRIE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31768-5050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-891-2442
-----------------------------------------------------
Fax | 229-890-9826
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 296
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31722-0296
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-324-2035
-----------------------------------------------------
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 | RPH023684
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------