Provider Demographics
NPI:1073803839
Name:FUSSELL, CECIL H JR
Entity type:Individual
Prefix:
First Name:CECIL
Middle Name:H
Last Name:FUSSELL
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 TURNBERRY CT
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-6743
Mailing Address - Country:US
Mailing Address - Phone:229-226-5207
Mailing Address - Fax:
Practice Address - Street 1:74 N SCOTT ST
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-1247
Practice Address - Country:US
Practice Address - Phone:229-336-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9730183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist