Healthcare Provider Details

I. General information

NPI: 1811550528
Provider Name (Legal Business Name): SYNERGEN RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 06/18/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3990 FLOWERS RD STE 530
DORAVILLE GA
30360-3195
US

IV. Provider business mailing address

3990 FLOWERS RD STE 530
DORAVILLE GA
30360-3195
US

V. Phone/Fax

Practice location:
  • Phone: 404-585-7517
  • Fax: 404-900-9209
Mailing address:
  • Phone: 404-585-7517
  • Fax: 404-900-9209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN PERSONIUS
Title or Position: OWNER
Credential:
Phone: 478-951-6066