Provider Demographics
NPI:1932229242
Name:BALTZ, MARLA WINGE (PHARMD)
Entity type:Individual
Prefix:MRS
First Name:MARLA
Middle Name:WINGE
Last Name:BALTZ
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 WATERS EDGE DR
Mailing Address - Street 2:
Mailing Address - City:LIZELLA
Mailing Address - State:GA
Mailing Address - Zip Code:31052-3629
Mailing Address - Country:US
Mailing Address - Phone:478-935-3507
Mailing Address - Fax:
Practice Address - Street 1:785 HWY. 96
Practice Address - Street 2:
Practice Address - City:BONAIRE
Practice Address - State:GA
Practice Address - Zip Code:31005
Practice Address - Country:US
Practice Address - Phone:478-987-7142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019574183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist