MEDICARE: MLK PHARMACY2.0

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1043817208
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MLK PHARMACY2.0

Provider Business Mailing Address
First Line	:	2457 MLK JR DR SW STE A
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-1712
Country	:	US
Telephone Number	:	678-705-5750
Fax Number	:	404-500-2152

Provider Business Practice Location Address
First Line	:	2457 MLK JR DR SW STE A
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30311-1712
Country	:	US
Telephone Number	:	678-705-5750
Fax Number	:	404-500-2152

Authorized Official
Title or Position	:	OWNER
Name	:	PRINCE WALKER
Credential	:
Telephone Number	:	202-384-9370

Provider Enumeration Date	:	10/01/2020
Last Update Date	:	10/01/2020

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