Healthcare Provider Details

I. General information

NPI: 1184175523
Provider Name (Legal Business Name): ICP HOLDINGS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8601 DUNWOODY PL STE 750
SANDY SPRINGS GA
30350-2519
US

IV. Provider business mailing address

8601 DUNWOODY PL STE 750
SANDY SPRINGS GA
30350-2519
US

V. Phone/Fax

Practice location:
  • Phone: 404-815-1610
  • Fax: 404-815-1609
Mailing address:
  • Phone: 404-815-1610
  • Fax: 404-815-1609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CASEY GAETANO
Title or Position: MANAGING PARTNER
Credential:
Phone: 404-814-1610