Healthcare Provider Details

I. General information

NPI: 1740823202
Provider Name (Legal Business Name): GWINNETT PULMONARY GROUP DULUTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2019
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3855 PLEASANT HILL RD STE 180
DULUTH GA
30096-8093
US

IV. Provider business mailing address

631 PROFESSIONAL DR STE 350
LAWRENCEVILLE GA
30046-3370
US

V. Phone/Fax

Practice location:
  • Phone: 770-995-0630
  • Fax:
Mailing address:
  • Phone: 770-995-0630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER THOMAS-ROLOFF
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 678-942-5985