Provider Demographics
NPI:1104107721
Name:SMITH, JANE COLEMAN
Entity type:Individual
Prefix:MRS
First Name:JANE
Middle Name:COLEMAN
Last Name:SMITH
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 1:2779 N COBB PKWY
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-3437
Mailing Address - Country:US
Mailing Address - Phone:770-795-1838
Mailing Address - Fax:
Practice Address - Street 1:2779 N COBB PKWY
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-3437
Practice Address - Country:US
Practice Address - Phone:770-795-1838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH012512183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist