Healthcare Provider Details

I. General information

NPI: 1114330107
Provider Name (Legal Business Name): JENNIFER GADDIE PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2014
Last Update Date: 06/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 LOVVORN AVE
BOWDON GA
30108-1141
US

IV. Provider business mailing address

203 BRAZELL ST
HOGANSVILLE GA
30230-1109
US

V. Phone/Fax

Practice location:
  • Phone: 770-258-3310
  • Fax:
Mailing address:
  • Phone: 678-621-3068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH027251
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: