Healthcare Provider Details

I. General information

NPI: 1104543826
Provider Name (Legal Business Name): REDIET G YEMANE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 10/24/2022
Certification Date: 10/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1038 US HIGHWAY 80 W
POOLER GA
31322-2114
US

IV. Provider business mailing address

1038 US HIGHWAY 80 W
POOLER GA
31322-2114
US

V. Phone/Fax

Practice location:
  • Phone: 912-748-5155
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH031698
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: