Healthcare Provider Details

I. General information

NPI: 1598256364
Provider Name (Legal Business Name): AUSTIN TULL PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2018
Last Update Date: 05/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2260 HOLLY SPRINGS PKWY STE 180
CANTON GA
30115-9580
US

IV. Provider business mailing address

2260 HOLLY SPRINGS PKWY STE 180
CANTON GA
30115-9580
US

V. Phone/Fax

Practice location:
  • Phone: 770-704-6161
  • Fax: 770-704-6171
Mailing address:
  • Phone: 770-704-6161
  • Fax: 770-704-6171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License Number4150329
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number027151
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: