Provider Demographics
NPI:1306144662
Name:HARRIS, ANGELINE HYATT
Entity type:Individual
Prefix:
First Name:ANGELINE
Middle Name:HYATT
Last Name:HARRIS
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 1:2169 POPLAR RD
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-1628
Mailing Address - Country:US
Mailing Address - Phone:770-253-5229
Mailing Address - Fax:
Practice Address - Street 1:3055 HIGHWAY 34 E
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2179
Practice Address - Country:US
Practice Address - Phone:770-252-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-09
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12401183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist