Healthcare Provider Details

I. General information

NPI: 1356342042
Provider Name (Legal Business Name): KETAYOUN DAVARI PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/03/2005
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

12130 LEEWARD WALK CIR
ALPHARETTA GA
30005-7478
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-6111
  • Fax: 404-417-2936
Mailing address:
  • Phone: 678-525-2019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberRPH019071
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: