Provider Demographics
NPI:1972076396
Name:RUST, JOHN THOMAS (PHARMACIST)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
Last Name:RUST
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1289 FELLOWS RD
Mailing Address - Street 2:
Mailing Address - City:ROCHELLE
Mailing Address - State:GA
Mailing Address - Zip Code:31079-3907
Mailing Address - Country:US
Mailing Address - Phone:229-324-2882
Mailing Address - Fax:
Practice Address - Street 1:775 GA HIGHWAY 122 W
Practice Address - Street 2:
Practice Address - City:HAHIRA
Practice Address - State:GA
Practice Address - Zip Code:31632-1066
Practice Address - Country:US
Practice Address - Phone:229-794-2989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH031027183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH031027OtherPHARMACIST LICENSE