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Individual

MRS. DETRA ELAINE PROVOST

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
RPH

Contact information

Practice address
4223 WASHINGTON RD, EVANS, GA 30809-3069
(706) 869-0937
(706) 993-9781
Mailing address
114 ABERDEEN DR, AIKEN, SC 29803-7100
(803) 649-3603
(803) 649-3603

Taxonomy

Speciality
Code
Description
License number
State
183500000X
Pharmacist
32754
TX
183500000X
Pharmacist
8706
SC
183500000X
Pharmacist
Primary
RPH18214
GA

Other

Enumeration date
01/24/2012
Last updated
01/24/2012
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