MEDICARE: KIM NGA DANG

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	028544	GA

General Provider Information

NPI Number	:	1528699469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM NGA DANG

Provider Business Mailing Address
First Line	:	2700 BRASELTON HWY
Second Line	:
City	:	DACULA
State	:	GA
Zip	:	30019-3262
Country	:	US
Telephone Number	:	770-614-1022
Fax Number	:

Provider Business Practice Location Address
First Line	:	2700 BRASELTON HWY
Second Line	:
City	:	DACULA
State	:	GA
Zip	:	30019-3262
Country	:	US
Telephone Number	:	678-765-5146
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2020
Last Update Date	:	02/08/2021

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