Provider Demographics
NPI:1063633345
Name:BARBOSA, THERESA ANN
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:BARBOSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 765
Mailing Address - Street 2:
Mailing Address - City:DAWSON
Mailing Address - State:GA
Mailing Address - Zip Code:39842-0765
Mailing Address - Country:US
Mailing Address - Phone:229-889-2083
Mailing Address - Fax:
Practice Address - Street 1:2418 SYLVESTER RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31705-2468
Practice Address - Country:US
Practice Address - Phone:229-889-0792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019029183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist