Healthcare Provider Details

I. General information

NPI: 1780281469
Provider Name (Legal Business Name): KHATIJA JIVANI PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2020
Last Update Date: 11/27/2023
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MEDICAL CENTER BLVD
LAWRENCEVILLE GA
30046-7694
US

IV. Provider business mailing address

1200 LAKE WASHINGTON CIR
LAWRENCEVILLE GA
30043-6663
US

V. Phone/Fax

Practice location:
  • Phone: 678-312-4149
  • Fax:
Mailing address:
  • Phone: 678-697-8670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number026780
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: