Provider Demographics
NPI:1104145796
Name:HARRIS, CARL CHRIS SR (RPH)
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:CHRIS
Last Name:HARRIS
Suffix:SR
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:CARL
Other - Middle Name:CHRIS
Other - Last Name:HARRIS
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:102 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545-1171
Mailing Address - Country:US
Mailing Address - Phone:912-588-1035
Mailing Address - Fax:912-588-7016
Practice Address - Street 1:102 S 1ST ST
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-1171
Practice Address - Country:US
Practice Address - Phone:912-588-1035
Practice Address - Fax:912-588-7016
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-22
Last Update Date:2010-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA13029183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA13029OtherSTATE PHARMACIST LICENSE NUMBER