MEDICARE: MR. JOHN WAYNE WHITEHEAD RPH

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	RPH010053	GA

General Provider Information

NPI Number	:	1669768917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN WAYNE WHITEHEAD RPH

Provider Business Mailing Address
First Line	:	1591 BRADLEY PARK DR
Second Line	:	T-1179
City	:	COLUMBUS
State	:	GA
Zip	:	31904-3071
Country	:	US
Telephone Number	:	706-327-8201
Fax Number	:	706-327-8201

Provider Business Practice Location Address
First Line	:	1591 BRADLEY PARK DR
Second Line	:	T-1179
City	:	COLUMBUS
State	:	GA
Zip	:	31904-3071
Country	:	US
Telephone Number	:	706-327-8201
Fax Number	:	706-327-8201

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

Provider Enumeration Date	:	06/24/2011
Last Update Date	:	06/24/2011

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