Healthcare Provider Details

I. General information

NPI: 1558667899
Provider Name (Legal Business Name): AIYANNA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2011
Last Update Date: 03/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 BOB WHITE AVE
BLAKELY GA
39823-2630
US

IV. Provider business mailing address

76002 GLOVER LN
YULEE FL
32097-2810
US

V. Phone/Fax

Practice location:
  • Phone: 404-579-0874
  • Fax:
Mailing address:
  • Phone: 404-579-0874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT JAMES GLOVER JR.
Title or Position: MANGER
Credential:
Phone: 404-579-0874