=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043814718
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HUZEFA EBRAHIMJI
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2020
-----------------------------------------------------
Last Update Date | 11/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1140 N HAIRSTON RD
-----------------------------------------------------
City | STONE MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30083-5800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-292-0484
-----------------------------------------------------
Fax | 404-299-3629
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 593 AXTON CT
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30044-5217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-597-9766
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RPH22998
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 9730
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------