Healthcare Provider Details

I. General information

NPI: 1558560326
Provider Name (Legal Business Name): GWINNETT CLINIC LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 11/07/2025
Certification Date: 11/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 PHILIP BLVD STE 102
LAWRENCEVILLE GA
30046-8737
US

IV. Provider business mailing address

475 PHILIP BLVD STE 102
LAWRENCEVILLE GA
30046-8737
US

V. Phone/Fax

Practice location:
  • Phone: 678-226-6212
  • Fax: 678-225-4036
Mailing address:
  • Phone: 678-226-6212
  • Fax: 678-225-4036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DEEP SHAH
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 678-428-4714