Healthcare Provider Details

I. General information

NPI: 1316261795
Provider Name (Legal Business Name): DEIRDRE JOI WORTHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2010
Last Update Date: 03/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 DUNWOODY PARK STE 102
ATLANTA GA
30338
US

IV. Provider business mailing address

5 DUNWOODY PARK STE 102
ATLANTA GA
30338
US

V. Phone/Fax

Practice location:
  • Phone: 678-441-0045
  • Fax: 678-441-0079
Mailing address:
  • Phone: 678-441-0045
  • Fax: 678-441-0079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH017511
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License NumberRPH017511
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: