Healthcare Provider Details

I. General information

NPI: 1386122240
Provider Name (Legal Business Name): CHRISTOPHER JOSEPH FAGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2018
Last Update Date: 08/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 PEACHTREE RD NW
ATLANTA GA
30305-4915
US

IV. Provider business mailing address

1210 MICHAEL RD NW
MONROE GA
30656-4402
US

V. Phone/Fax

Practice location:
  • Phone: 770-375-8205
  • Fax:
Mailing address:
  • Phone: 770-375-8205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH030763
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: