Provider Demographics
NPI:1871144865
Name:MCCORMICK, TAKIA CHANTEL (PHARMD)
Entity type:Individual
Prefix:
First Name:TAKIA
Middle Name:CHANTEL
Last Name:MCCORMICK
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 1:5046 GA HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:31833-5108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:710 CENTER ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1527
Practice Address - Country:US
Practice Address - Phone:706-571-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-22
Last Update Date:2019-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH-31410183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist