MEDICARE: DR. VICTORIA GANKA

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	RPH029244	GA

General Provider Information

NPI Number	:	1902438054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VICTORIA GANKA

Provider Business Mailing Address
First Line	:	950 MODA DR
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30316-6601
Country	:	US
Telephone Number	:	770-855-1987
Fax Number	:

Provider Business Practice Location Address
First Line	:	1745 HIGHWAY 138 SE
Second Line	:
City	:	CONYERS
State	:	GA
Zip	:	30013-5748
Country	:	US
Telephone Number	:	770-922-0447
Fax Number	:

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

Provider Enumeration Date	:	02/06/2020
Last Update Date	:	02/06/2020

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