Provider Demographics
NPI:1306568258
Name:PAM, MARK GREGORY
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:GREGORY
Last Name:PAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 NORTH EAST DYKES STREET
Mailing Address - Street 2:
Mailing Address - City:COCHRAN
Mailing Address - State:GA
Mailing Address - Zip Code:31014
Mailing Address - Country:US
Mailing Address - Phone:478-934-9431
Mailing Address - Fax:478-934-0504
Practice Address - Street 1:202 NE DYKES STREET
Practice Address - Street 2:
Practice Address - City:COCHRAN
Practice Address - State:GA
Practice Address - Zip Code:31014
Practice Address - Country:US
Practice Address - Phone:478-934-9431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA15622183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist