Provider Demographics
NPI:1750594719
Name:LARGE, THOMAS JEFF (RPH)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:JEFF
Last Name:LARGE
Suffix:
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 1:406 COURTHOUSE SQUARE
Mailing Address - Street 2:
Mailing Address - City:BUCHANAN
Mailing Address - State:GA
Mailing Address - Zip Code:30113
Mailing Address - Country:US
Mailing Address - Phone:770-646-3570
Mailing Address - Fax:770-646-3571
Practice Address - Street 1:406 COURTHOUSE SQUARE
Practice Address - Street 2:
Practice Address - City:BUCHANAN
Practice Address - State:GA
Practice Address - Zip Code:30113
Practice Address - Country:US
Practice Address - Phone:770-646-3570
Practice Address - Fax:770-646-3571
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014083183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist