Healthcare Provider Details

I. General information

NPI: 1194769968
Provider Name (Legal Business Name): HENRY JEW PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 CLAIRMONT RD VA MEDICAL CENTER
DECATUR GA
30033-4004
US

IV. Provider business mailing address

1285 CHELSEY LN
ALPHARETTA GA
30004-1167
US

V. Phone/Fax

Practice location:
  • Phone: 404-321-6111
  • Fax: 404-329-2238
Mailing address:
  • Phone: 770-663-4311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208U00000X
TaxonomyClinical Pharmacology Physician
License Number11323
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: