1164739918 NPI number — MR. ROBERT ERVIN EVERETT JR. RPH

Table of content: MR. ROBERT ERVIN EVERETT JR. RPH (NPI 1164739918)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164739918 NPI number — MR. ROBERT ERVIN EVERETT JR. RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVERETT
Provider First Name:
ROBERT
Provider Middle Name:
ERVIN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
RPH
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164739918
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 367
Provider Second Line Business Mailing Address:
1050 CLOTFELTER LN
Provider Business Mailing Address City Name:
BOGART
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30622-0367
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-338-7657
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1918 RAILROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATHAM
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30666-1875
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-725-1122
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  RPH013637 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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