Healthcare Provider Details

I. General information

NPI: 1639619307
Provider Name (Legal Business Name): MEDICINAL PLUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2017
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2443 CENTER POINTE CIR SW
ATLANTA GA
30315-7309
US

IV. Provider business mailing address

2443 CENTER POINTE CIR SW
ATLANTA GA
30315-7309
US

V. Phone/Fax

Practice location:
  • Phone: 470-344-4696
  • Fax:
Mailing address:
  • Phone: 470-344-4696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberRPH26521
License Number StateGA

VIII. Authorized Official

Name: DR. LATASHA STALLWORTH
Title or Position: OWNER
Credential: PHARM D
Phone: 404-904-4282