Provider Demographics
NPI:1528443009
Name:MANLEY, WARREN
Entity type:Individual
Prefix:
First Name:WARREN
Middle Name:
Last Name:MANLEY
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 1:117 POLK LN
Mailing Address - Street 2:
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750-6302
Mailing Address - Country:US
Mailing Address - Phone:229-831-2629
Mailing Address - Fax:
Practice Address - Street 1:220 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750-2438
Practice Address - Country:US
Practice Address - Phone:229-423-0521
Practice Address - Fax:229-423-7147
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012597183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist