Healthcare Provider Details

I. General information

NPI: 1295019495
Provider Name (Legal Business Name): MR. PANACKAL O JOHN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2011
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

472 S ENOTA DR
GAINSVILLE GA
30501
US

IV. Provider business mailing address

2304 MALDEN PARK DR
BUFORD GA
30519
US

V. Phone/Fax

Practice location:
  • Phone: 770-535-3750
  • Fax: 770-535-4071
Mailing address:
  • Phone: 678-985-2712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH021035
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: