Healthcare Provider Details

I. General information

NPI: 1710074505
Provider Name (Legal Business Name): GERIATRIC CARE CONSULTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3641 LANIER DR
DOUGLASVILLE GA
30135-7165
US

IV. Provider business mailing address

3641 LANIER DR
DOUGLASVILLE GA
30135-7165
US

V. Phone/Fax

Practice location:
  • Phone: 770-489-2110
  • Fax: 770-732-5514
Mailing address:
  • Phone: 770-489-2110
  • Fax: 770-732-5514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License NumberRPH022455
License Number StateGA

VIII. Authorized Official

Name: DR. MARK ANTHONY TERRY
Title or Position: PRESIDENT
Credential: PHARMD.
Phone: 770-489-2110