1295089126 NPI number — RICKY ALLEN MCINTYRE RPH

Table of content: RICKY ALLEN MCINTYRE RPH (NPI 1295089126)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295089126 NPI number — RICKY ALLEN MCINTYRE RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCINTYRE
Provider First Name:
RICKY
Provider Middle Name:
ALLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
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:
1295089126
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 622
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIDALIA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30475-0622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-245-1810
Provider Business Mailing Address Fax Number:
912-537-8709

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1527 ORANGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIDALIA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30474-5916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-245-1810
Provider Business Practice Location Address Fax Number:
912-537-8709
Provider Enumeration Date:
10/30/2012

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:  RPH014504 , 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)