Healthcare Provider Details

I. General information

NPI: 1689088064
Provider Name (Legal Business Name): JIMMY GBEMI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2014
Last Update Date: 08/14/2025
Certification Date: 08/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 WINDWARD HLS
MCDONOUGH GA
30253-5991
US

IV. Provider business mailing address

1776 PANOLA RD
ELLENWOOD GA
30294-2856
US

V. Phone/Fax

Practice location:
  • Phone: 478-278-8155
  • Fax:
Mailing address:
  • Phone: 770-545-8555
  • Fax: 770-545-8556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number023287
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: