Provider Demographics
NPI:1043822067
Name:MITCHAM, MARLA MARIE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MARLA
Middle Name:MARIE
Last Name:MITCHAM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MYRTLE BLVD.
Mailing Address - Street 2:PHARMACY BLDG. 15 ROOM G12
Mailing Address - City:GRACEWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30812
Mailing Address - Country:US
Mailing Address - Phone:706-790-2496
Mailing Address - Fax:706-790-2340
Practice Address - Street 1:100 MYRTLE BLVD.
Practice Address - Street 2:PHARMACY BLDG. 15 ROOM G12
Practice Address - City:GRACEWOOD
Practice Address - State:GA
Practice Address - Zip Code:30812
Practice Address - Country:US
Practice Address - Phone:706-790-2496
Practice Address - Fax:706-790-2340
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH029883183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH029883OtherPHARMACIST LICENSE