Provider Demographics
NPI:1043312416
Name:FLORENCE, CAROLYN LOTT (RPH)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:LOTT
Last Name:FLORENCE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MRS
Other - First Name:CAROLYN
Other - Middle Name:LOTT
Other - Last Name:FLORENCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:PO BOX 791
Mailing Address - Street 2:
Mailing Address - City:LA FAYETTE
Mailing Address - State:GA
Mailing Address - Zip Code:30728-0791
Mailing Address - Country:US
Mailing Address - Phone:706-638-3114
Mailing Address - Fax:706-638-7713
Practice Address - Street 1:324 WEST PATTON ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728-0791
Practice Address - Country:US
Practice Address - Phone:706-638-3114
Practice Address - Fax:706-638-7713
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11833183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00182762BMedicaid
GA00182762AMedicaid
GA0564880001Medicare NSC