| None | |
|
1790 Mulkey Rd Ste 3a Austell GA 30106-1122 | |
| (770) 693-9388 | |
| (770) 693-9537 |
| Full Name | None |
|---|---|
| Speciality | Clinic/Center |
| Location | 1790 Mulkey Rd Ste 3a, Austell, Georgia |
| Authorized Official Name and Position | Kimberly C Henderson (PHARMACIST) |
| Authorized Official Contact | 4042718768 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| None 15 Pointe Ridge Dr Atlanta GA 30328-2755 Ph: (404) 271-8768 | None 1790 Mulkey Rd Ste 3a Austell GA 30106-1122 Ph: (770) 693-9388 |
| NPI Number | 1154889665 |
|---|---|
| Provider Enumeration Date | 03/05/2019 |
| Last Update Date | 04/06/2023 |
| Medicare PECOS PAC ID | 8628408309 |
|---|---|
| Medicare Enrollment ID | O20200421000042 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1154889665 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | (* (Not Available)) | Secondary |
| 261QR0405X | Clinic/center - Rehabilitation, Substance Use Disorder | (* (Not Available)) | Primary |
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