Provider Demographics
NPI:1861944712
Name:WYNNE, ROBERT ANDREW (RPH)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:ANDREW
Last Name:WYNNE
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 1:4046 GOSHEN LAKE DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-9109
Mailing Address - Country:US
Mailing Address - Phone:706-339-9931
Mailing Address - Fax:
Practice Address - Street 1:3549 CHAMBLEE TUCKER RD
Practice Address - Street 2:
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341-4409
Practice Address - Country:US
Practice Address - Phone:770-455-8620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH029568183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist