{
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"EIN": null,
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"FirstLineMailingAddress": "2246 HOLLY TERRACE LN",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "TALLAHASSEE",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "32309-1488",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "229-551-2377",
"MailingAddressFaxNumber": "229-551-8610",
"FirstLinePracticeLocationAddress": "2705 E PINETREE BLVD STE F",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "THOMASVILLE",
"PracticeLocationAddressStateName": "GA",
"PracticeLocationAddressPostalCode": "31792-4875",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "229-551-2377",
"PracticeLocationAddressFaxNumber": "229-551-8610",
"EnumerationDate": "02/13/2024",
"LastUpdateDate": "02/13/2024",
"NPIDeactivationReasonCode": null,
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"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
"Gender": "Male",
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"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "183500000X",
"TaxonomyName": "Pharmacist",
"LicenseNumber": "RPH027139",
"LicenseNumberStateCode": "GA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}