Detra Elaine Provost, RPH

Primary specialty

PharmacistTaxonomy code 183500000X

License

RPH18214 Issued in GA

Practice address

4223 Washington Rd
Evans, GA 30809-3069

Phone

(706) 869-0937

Fax

(706) 993-9781

NPI assigned

Jan 24, 2012

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other names 1

• Mrs. Detra Elaine Wooten Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Registered Pharmacist

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1327363200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1327363200000",
    "number": "1265703128",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "114 ABERDEEN DR",
            "city": "AIKEN",
            "state": "SC",
            "postal_code": "298037100",
            "telephone_number": "803-649-3603",
            "fax_number": "803-649-3603"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4223 WASHINGTON RD",
            "city": "EVANS",
            "state": "GA",
            "postal_code": "308093069",
            "telephone_number": "706-869-0937",
            "fax_number": "706-993-9781"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PROVOST",
        "first_name": "DETRA",
        "middle_name": "ELAINE",
        "name_prefix": "Mrs.",
        "credential": "RPH",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2012-01-24",
        "last_updated": "2012-01-24",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "183500000X",
            "taxonomy_group": "",
            "desc": "Pharmacist",
            "state": "GA",
            "license": "RPH18214",
            "primary": true
        },
        {
            "code": "183500000X",
            "taxonomy_group": "",
            "desc": "Pharmacist",
            "state": "SC",
            "license": "8706",
            "primary": false
        },
        {
            "code": "183500000X",
            "taxonomy_group": "",
            "desc": "Pharmacist",
            "state": "TX",
            "license": "32754",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "DETRA",
            "last_name": "WOOTEN",
            "middle_name": "ELAINE",
            "prefix": "MRS.",
            "credential": "RPH",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

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• Baron D Pritchard, PHARM. D
• Tasha Andrea Pritchett, LCSW
• Pruitthealth - Evans, LLC
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• Jennifer Pry
• Psych Consultants PC
• PT Solutions of Acworth LLC

• Pharmacist in Evans, GA
• Providers in Evans, GA by specialty
• Pharmacist in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 24, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.