Provider Demographics
NPI:1023594736
Name:KIRSCH, VANETA G
Entity type:Individual
Prefix:MRS
First Name:VANETA
Middle Name:G
Last Name:KIRSCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:LAVONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30553-0088
Mailing Address - Country:US
Mailing Address - Phone:678-640-8491
Mailing Address - Fax:
Practice Address - Street 1:3886 GA HWY 17
Practice Address - Street 2:
Practice Address - City:TOCOOA
Practice Address - State:GA
Practice Address - Zip Code:30577
Practice Address - Country:US
Practice Address - Phone:706-282-1193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH014975183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist