Healthcare Provider Details

I. General information

NPI: 1003844408
Provider Name (Legal Business Name): ROOSEVELT N/A DAVIS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 CLAIRMONT RD
DECATUR GA
30033-4004
US

IV. Provider business mailing address

801 W PONCE DE LEON AVE
DECATUR GA
30030-2859
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-6111
  • Fax: 404-327-4957
Mailing address:
  • Phone: 678-296-5052
  • Fax: 404-327-4957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number014377
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: