Healthcare Provider Details

I. General information

NPI: 1912205907
Provider Name (Legal Business Name): KNIKKI CHILDS PENDLETON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2011
Last Update Date: 08/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 AUDUBON CT SW
ATLANTA GA
30311-2472
US

IV. Provider business mailing address

1401 AUDUBON CT SW
ATLANTA GA
30311-2472
US

V. Phone/Fax

Practice location:
  • Phone: 404-668-6876
  • Fax: 404-758-0715
Mailing address:
  • Phone: 404-668-6876
  • Fax: 908-243-9050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number34941
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: