Provider Demographics
NPI:1720099807
Name:MILLER, CHARLES W (RPH)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:W
Last Name:MILLER
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 1:2111 COUNTY ROAD 4670
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:TX
Mailing Address - Zip Code:75551-7813
Mailing Address - Country:US
Mailing Address - Phone:903-796-9372
Mailing Address - Fax:
Practice Address - Street 1:510 E STONER AVE DEPT 119
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-221-8411
Practice Address - Fax:318-429-5750
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30787183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX30787OtherPHARMACIST LICENSE NUMBER