Provider Demographics
NPI:1851849657
Name:LIVELY, AUSTIN (RPH)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:LIVELY
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 1:5370 CAMPBELLTON FAIRBURN RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-2296
Mailing Address - Country:US
Mailing Address - Phone:770-774-3605
Mailing Address - Fax:
Practice Address - Street 1:5370 CAMPBELLTON FAIRBURN RD
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-2296
Practice Address - Country:US
Practice Address - Phone:770-774-3605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029308183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist