Provider Demographics
NPI:1679163992
Name:MIZE, HERSCHEL EARLE
Entity type:Individual
Prefix:
First Name:HERSCHEL
Middle Name:EARLE
Last Name:MIZE
Suffix:
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 1:959 BIG A RD
Mailing Address - Street 2:
Mailing Address - City:TOCCOA
Mailing Address - State:GA
Mailing Address - Zip Code:30577-6026
Mailing Address - Country:US
Mailing Address - Phone:706-886-6267
Mailing Address - Fax:706-282-1838
Practice Address - Street 1:959 BIG A RD
Practice Address - Street 2:
Practice Address - City:TOCCOA
Practice Address - State:GA
Practice Address - Zip Code:30577-6026
Practice Address - Country:US
Practice Address - Phone:706-886-6267
Practice Address - Fax:706-282-1838
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH012415183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist