Healthcare Provider Details

I. General information

NPI: 1235476177
Provider Name (Legal Business Name): STEVE GEDALY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2013
Last Update Date: 01/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4279 ROSWELL RD
ATLANTA GA
30342-3769
US

IV. Provider business mailing address

4279 ROSWELL RD
ATLANTA GA
30342-3769
US

V. Phone/Fax

Practice location:
  • Phone: 404-843-4358
  • Fax: 404-843-4302
Mailing address:
  • Phone: 404-843-4358
  • Fax: 404-843-4302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH018089
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: