Healthcare Provider Details

I. General information

NPI: 1902713662
Provider Name (Legal Business Name): HEATHER IVY SOCIETY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2193 CASCADE RD SW
ATLANTA GA
30311-2862
US

IV. Provider business mailing address

2193 CASCADE RD SW
ATLANTA GA
30311-2862
US

V. Phone/Fax

Practice location:
  • Phone: 844-884-9691
  • Fax: 404-907-4052
Mailing address:
  • Phone: 844-884-9691
  • Fax: 404-907-4052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: ZANDRAETTA TIMS COOK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 615-305-9006