Healthcare Provider Details

I. General information

NPI: 1861314643
Provider Name (Legal Business Name): TAJENDRA PRASAD PHARM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 HOUSTON LAKE RD UNIT B600
PERRY GA
31069-2684
US

IV. Provider business mailing address

12003 WATSON BLVD
BYRON GA
31008-5577
US

V. Phone/Fax

Practice location:
  • Phone: 478-538-2788
  • Fax:
Mailing address:
  • Phone: 478-538-2788
  • Fax:

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: MALAY PATEL
Title or Position: OWNER/PIC
Credential: PHARMD
Phone: 478-538-2788