Basic Information
Provider Information
NPI: 1003292723
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BROOKS
FirstName: JAMES
MiddleName: STEVEN
NamePrefix:  
NameSuffix:  
Credential: PHARMD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 409 W 3RD ST
Address2:  
City: DONALSONVILLE
State: GA
PostalCode: 398451511
CountryCode: US
TelephoneNumber: 2295242596
FaxNumber: 2295242631
Practice Location
Address1: 409 W 3RD ST
Address2:  
City: DONALSONVILLE
State: GA
PostalCode: 398451511
CountryCode: US
TelephoneNumber: 2295242596
FaxNumber: 2295242631
Other Information
ProviderEnumerationDate: 08/04/2015
LastUpdateDate: 08/04/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000XPS29249FLN Pharmacy Service ProvidersPharmacist 
183500000X017200GAY Pharmacy Service ProvidersPharmacist 

No ID Information.


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