Healthcare Provider Details

I. General information

NPI: 1720074131
Provider Name (Legal Business Name): GARY L. BIVINS R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 JOHNSON FERRY RD NE
ATLANTA GA
30342-1606
US

IV. Provider business mailing address

3805 HEDGECLIFF CT
ALPHARETTA GA
30022-7116
US

V. Phone/Fax

Practice location:
  • Phone: 404-851-6270
  • Fax: 404-303-3323
Mailing address:
  • Phone: 770-740-1810
  • Fax: 770-740-9371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number014009
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: