Provider Demographics
NPI:1972103422
Name:SMALL, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:SMALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2386 WILLINGTON SHOALS PL SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-8513
Mailing Address - Country:US
Mailing Address - Phone:404-372-8564
Mailing Address - Fax:
Practice Address - Street 1:2510 REDMOND CIR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1913
Practice Address - Country:US
Practice Address - Phone:706-235-3699
Practice Address - Fax:706-235-4212
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH024925183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist