Provider Demographics
NPI:1548690423
Name:ETHRIDGE, LARRY (RPH)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:
Last Name:ETHRIDGE
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 1:4240 LUTHER WARD RD
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-1184
Mailing Address - Country:US
Mailing Address - Phone:770-726-9837
Mailing Address - Fax:770-726-9837
Practice Address - Street 1:4240 LUTHER WARD RD
Practice Address - Street 2:
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-1184
Practice Address - Country:US
Practice Address - Phone:770-726-9837
Practice Address - Fax:770-726-9837
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH010737183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH010737OtherPHARMACY LICENSE