=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083997258
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARLA ALDRIDGE BANKS PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2011
-----------------------------------------------------
Last Update Date | 11/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 MARIETTA HWY
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30114-2303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-880-0575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 RIVERSTONE VIS STE 102
-----------------------------------------------------
City | BLUE RIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30513-6630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-258-4140
-----------------------------------------------------
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 | PS34248
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 020252
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------