Healthcare Provider Details

I. General information

NPI: 1962823567
Provider Name (Legal Business Name): KSYRX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2013
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 E PARK PLACE BLVD STE 500
STONE MOUNTAIN GA
30087
US

IV. Provider business mailing address

PO BOX 958277
DULUTH GA
30095-9539
US

V. Phone/Fax

Practice location:
  • Phone: 770-696-9146
  • Fax: 470-299-3159
Mailing address:
  • Phone: 281-755-4922
  • Fax: 470-299-3159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHHH000060
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: IBRAHIM SYLLA
Title or Position: OWNER/PIC
Credential: RPH
Phone: 770-696-9146