Provider Demographics
NPI:1548859515
Name:BLACK, HAYDEN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:HAYDEN
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 MAGNOLIA LN
Mailing Address - Street 2:
Mailing Address - City:CORNELIA
Mailing Address - State:GA
Mailing Address - Zip Code:30531-2297
Mailing Address - Country:US
Mailing Address - Phone:706-776-3784
Mailing Address - Fax:706-776-3788
Practice Address - Street 1:130 MAGNOLIA LN
Practice Address - Street 2:
Practice Address - City:CORNELIA
Practice Address - State:GA
Practice Address - Zip Code:30531-2297
Practice Address - Country:US
Practice Address - Phone:706-776-3784
Practice Address - Fax:706-776-3788
Is Sole Proprietor?:No
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH030715183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist