Healthcare Provider Details

I. General information

NPI: 1396658951
Provider Name (Legal Business Name): LOWTIDE PHARMACY ATLANTA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91135 EAST METRO PKWY
OXFORD GA
30054-4226
US

IV. Provider business mailing address

91135 EAST METRO PKWY
OXFORD GA
30054-4226
US

V. Phone/Fax

Practice location:
  • Phone: 470-682-2068
  • Fax: 678-750-1035
Mailing address:
  • Phone: 470-682-2068
  • Fax: 678-750-1035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. KELECHUKWU ITEOGU
Title or Position: PIC/MANAGING PARTNER
Credential: PHARMD
Phone: 478-954-2364