Healthcare Provider Details

I. General information

NPI: 1679443501
Provider Name (Legal Business Name): GLIMPSE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2025
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3970 PEACHTREE INDUSTRIAL BLVD STE 100
BERKELEY LAKE GA
30096-4813
US

IV. Provider business mailing address

3970 PEACHTREE INDUSTRIAL BLVD STE 100
BERKELEY LAKE GA
30096-4813
US

V. Phone/Fax

Practice location:
  • Phone: 404-556-8373
  • Fax:
Mailing address:
  • Phone: 404-556-8373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SURROUROSSADAT LAVASSANI
Title or Position: OWNER
Credential:
Phone: 404-556-8373