=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053973503
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KOMAL PATEL PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2019
-----------------------------------------------------
Last Update Date | 02/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3050 FIVE FORKS TRICKUM RD SW
-----------------------------------------------------
City | LILBURN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30047-1810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-985-3720
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1015 WATER SHINE WAY
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30078-7781
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-227-9619
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | 019951
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------