Provider Demographics
NPI:1306136171
Name:BRANNON, CARTER DALE (RPH)
Entity type:Individual
Prefix:MR
First Name:CARTER
Middle Name:DALE
Last Name:BRANNON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5650 TOCCOA DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-5803
Mailing Address - Country:US
Mailing Address - Phone:770-949-7418
Mailing Address - Fax:
Practice Address - Street 1:62 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1545
Practice Address - Country:US
Practice Address - Phone:770-459-9660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011568183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist