Healthcare Provider Details

I. General information

NPI: 1811512155
Provider Name (Legal Business Name): JYOTI SHRIVASTAVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2020
Last Update Date: 06/12/2020
Certification Date: 06/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 PEACHTREE CENTER AVE NE
ATLANTA GA
30303-1216
US

IV. Provider business mailing address

5655 GROVE PLACE XING SW
LILBURN GA
30047-8600
US

V. Phone/Fax

Practice location:
  • Phone: 866-787-6341
  • Fax:
Mailing address:
  • Phone: 404-431-9566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number33848
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number017662
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: