Healthcare Provider Details

I. General information

NPI: 1790317493
Provider Name (Legal Business Name): YANCY MAX WITT PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2020
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4920 ROSWELL RD
SANDY SPRINGS GA
30342-2686
US

IV. Provider business mailing address

1011 CHASTAIN PARK CT NE
ATLANTA GA
30342-3246
US

V. Phone/Fax

Practice location:
  • Phone: 404-843-3225
  • Fax: 404-303-8326
Mailing address:
  • Phone: 678-429-6629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRPH023722
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: