Provider Demographics
NPI:1306965330
Name:BROCK, WINSTON BURNUM JR (PHARMD)
Entity type:Individual
Prefix:DR
First Name:WINSTON
Middle Name:BURNUM
Last Name:BROCK
Suffix:JR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3077 FOWLSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-6632
Mailing Address - Country:US
Mailing Address - Phone:229-243-7255
Mailing Address - Fax:
Practice Address - Street 1:496 HWY 84 EAST
Practice Address - Street 2:RITE AID
Practice Address - City:CAIRO
Practice Address - State:GA
Practice Address - Zip Code:39828
Practice Address - Country:US
Practice Address - Phone:229-377-9286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA18698183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist