Provider Demographics
NPI:1194429712
Name:BAUMGARTNER, MIRANDA DESIREE (CPHT-ADV, CSPT)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:DESIREE
Last Name:BAUMGARTNER
Suffix:
Gender:F
Credentials:CPHT-ADV, CSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 AMELIA DR W
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-9373
Mailing Address - Country:US
Mailing Address - Phone:256-727-2765
Mailing Address - Fax:
Practice Address - Street 1:1 7TH ST STE 107
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-1305
Practice Address - Country:US
Practice Address - Phone:706-855-0155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHTC051881183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician