Healthcare Provider Details

I. General information

NPI: 1598623563
Provider Name (Legal Business Name): THERESA USTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11035 MEDLOCK BRIDGE RD STE 40
JOHNS CREEK GA
30097-1981
US

IV. Provider business mailing address

11035 MEDLOCK BRIDGE RD STE 40
JOHNS CREEK GA
30097-1981
US

V. Phone/Fax

Practice location:
  • Phone: 678-691-1375
  • Fax: 800-805-4561
Mailing address:
  • Phone: 678-691-1375
  • Fax: 800-805-4561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRPH028260
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH028260
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: