Healthcare Provider Details

I. General information

NPI: 1255937389
Provider Name (Legal Business Name): JAMES MICHAEL DESORBO RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2020
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4769 S MAIN ST
ACWORTH GA
30101-5339
US

IV. Provider business mailing address

3859 HAMPTON CREST LN NW
KENNESAW GA
30152-6991
US

V. Phone/Fax

Practice location:
  • Phone: 800-736-7519
  • Fax:
Mailing address:
  • Phone: 941-320-4614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License NumberRPH023439
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH023439
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: