Healthcare Provider Details

I. General information

NPI: 1578161253
Provider Name (Legal Business Name): MICHAEL C MGBEMENA PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2020
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2685 METROPOLITAN PKWY SW
ATLANTA GA
30315-7900
US

IV. Provider business mailing address

2068 MURRY TRL
MORROW GA
30260-1387
US

V. Phone/Fax

Practice location:
  • Phone: 404-209-6638
  • Fax:
Mailing address:
  • Phone: 404-277-9890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number031571
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: