MEDICARE: THERON GLENN FOX JR.

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	RPH010499	GA

General Provider Information

NPI Number	:	1841304383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERON GLENN FOX JR.

Provider Business Mailing Address
First Line	:	699 STARR CREEK RD
Second Line	:
City	:	RICHMOND HILL
State	:	GA
Zip	:	31324-6118
Country	:	US
Telephone Number	:	912-727-2240
Fax Number	:

Provider Business Practice Location Address
First Line	:	204 BUTLER AVE
Second Line	:
City	:	MIDWAY
State	:	GA
Zip	:	31320
Country	:	US
Telephone Number	:	912-884-9255
Fax Number	:

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

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	07/08/2007

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