Healthcare Provider Details

I. General information

NPI: 1639452998
Provider Name (Legal Business Name): MR. SONI K JOSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2011
Last Update Date: 09/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2075 GRAYSON HWY
GRAYSON GA
30017-1242
US

IV. Provider business mailing address

2008 ALCOVY SHOALS BLF
LAWRENCEVILLE GA
30045-2788
US

V. Phone/Fax

Practice location:
  • Phone: 770-338-0881
  • Fax:
Mailing address:
  • Phone: 678-407-0418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH022259
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: