Provider Demographics
NPI:1861091779
Name:HEDRICK, MARCUS LEE (PHARMACIST)
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:LEE
Last Name:HEDRICK
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:961 DURRELL ST
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1405
Mailing Address - Country:US
Mailing Address - Phone:678-389-1841
Mailing Address - Fax:
Practice Address - Street 1:3240 S COBB DR SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-4194
Practice Address - Country:US
Practice Address - Phone:770-433-3420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA017240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGA017240OtherGA EPH LOS ENSE