Provider Demographics
NPI:1548284920
Name:MCCORN, MARVIN OWEN III (RPH)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:OWEN
Last Name:MCCORN
Suffix:III
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 1:7890 JETT FERRY RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30350-4716
Mailing Address - Country:US
Mailing Address - Phone:770-842-0657
Mailing Address - Fax:770-393-0835
Practice Address - Street 1:8046 ROSWELL RD
Practice Address - Street 2:STE 202
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30350-7023
Practice Address - Country:US
Practice Address - Phone:770-671-0657
Practice Address - Fax:770-393-0835
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH010559183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist