Healthcare Provider Details

I. General information

NPI: 1871372342
Provider Name (Legal Business Name): SHADI YACOUB PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2023
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 TOWN BLVD NE STE A100
BROOKHAVEN GA
30319-3146
US

IV. Provider business mailing address

2230 CHESHIRE BRIDGE RD NE UNIT 512
ATLANTA GA
30324-4281
US

V. Phone/Fax

Practice location:
  • Phone: 404-233-7480
  • Fax:
Mailing address:
  • Phone: 404-593-1743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH034564
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: