Healthcare Provider Details

I. General information

NPI: 1073133773
Provider Name (Legal Business Name): LANA KUYKENDOLL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8501 HOSPITAL DR
DOUGLASVILLE GA
30134-2414
US

IV. Provider business mailing address

8501 HOSPITAL DR
DOUGLASVILLE GA
30134-2414
US

V. Phone/Fax

Practice location:
  • Phone: 770-949-3529
  • Fax: 770-920-5421
Mailing address:
  • Phone: 770-949-3529
  • Fax: 770-920-5421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRPH023251
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: