MEDICARE: MR. TOMMY P PORTER R.PH.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	012215	GA

General Provider Information

NPI Number	:	1548256514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TOMMY P PORTER R.PH.

Provider Business Mailing Address
First Line	:	129 N 2ND ST
Second Line	:
City	:	COCHRAN
State	:	GA
Zip	:	31014-8742
Country	:	US
Telephone Number	:	478-934-6344
Fax Number	:	478-934-8820

Provider Business Practice Location Address
First Line	:	129 N 2ND ST
Second Line	:
City	:	COCHRAN
State	:	GA
Zip	:	31014-8742
Country	:	US
Telephone Number	:	478-934-6344
Fax Number	:	478-934-8820

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2005
Last Update Date	:	04/24/2008

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