Provider Demographics
NPI:1053910018
Name:HENDERSON, LORA SUE (PHARMD)
Entity type:Individual
Prefix:
First Name:LORA
Middle Name:SUE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 HICKORY KNLS
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2050
Mailing Address - Country:US
Mailing Address - Phone:678-908-5585
Mailing Address - Fax:
Practice Address - Street 1:3455 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-6501
Practice Address - Country:US
Practice Address - Phone:770-476-7985
Practice Address - Fax:770-476-3437
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
GARPH019222183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist