Healthcare Provider Details

I. General information

NPI: 1972106094
Provider Name (Legal Business Name): VALERIE OMIDINA PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2020
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5764 PEACHTREE INDUSTRIAL BLVD
ATLANTA GA
30341-1908
US

IV. Provider business mailing address

PO BOX 724784
ATLANTA GA
31139-1784
US

V. Phone/Fax

Practice location:
  • Phone: 770-457-4401
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH024360
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: