Healthcare Provider Details

I. General information

NPI: 1497355465
Provider Name (Legal Business Name): FASIKA YIGEZU PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 JOHNSON FERRY RD
MARIETTA GA
30062-5657
US

IV. Provider business mailing address

2609 PETERBORO ROW
MARIETTA GA
30062-5877
US

V. Phone/Fax

Practice location:
  • Phone: 404-543-5916
  • Fax: 770-642-1493
Mailing address:
  • Phone: 404-543-5916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH026170
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: