Provider Demographics
NPI:1861573263
Name:CAGLE, WILLIAM GRADY JR
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:GRADY
Last Name:CAGLE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 EAST MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114
Mailing Address - Country:US
Mailing Address - Phone:770-479-5533
Mailing Address - Fax:770-479-9135
Practice Address - Street 1:196 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2707
Practice Address - Country:US
Practice Address - Phone:770-479-5533
Practice Address - Fax:770-479-9135
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8181183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00032051AMedicaid