Healthcare Provider Details

I. General information

NPI: 1962139303
Provider Name (Legal Business Name): GARY JOSEPH OPETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2022
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 JONESBORO RD
MCDONOUGH GA
30253-3725
US

IV. Provider business mailing address

3271 FLOWERS RD S APT Q
ATLANTA GA
30341-5687
US

V. Phone/Fax

Practice location:
  • Phone: 770-954-4375
  • Fax: 770-954-4374
Mailing address:
  • Phone: 850-217-0108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRPH033702
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: