Provider Demographics
NPI:1588771067
Name:WELLS, MICHAEL ANTHONY (RPH)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:WELLS
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 1:104 S GREEN ST
Mailing Address - Street 2:
Mailing Address - City:SWAINSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30401-3131
Mailing Address - Country:US
Mailing Address - Phone:478-237-8835
Mailing Address - Fax:478-237-9510
Practice Address - Street 1:104 S GREEN ST
Practice Address - Street 2:
Practice Address - City:SWAINSBORO
Practice Address - State:GA
Practice Address - Zip Code:30401-3131
Practice Address - Country:US
Practice Address - Phone:478-237-8835
Practice Address - Fax:478-237-9510
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016582183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist