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General NPI Number Information
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NPI Number | 1164015772
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Entity Type | Individual
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Provider Name | MATTHEW DONG HUN BAN
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Gender | Male
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Dates
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Enumeration Date | 02/15/2021
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Last Update Date | 02/15/2021
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Provider Practice Location Address
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Address Line | 1765 JONESBORO RD
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City | MCDONOUGH
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State | GA
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Zip | 30253-5969
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Country | US
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Telephone | 770-914-5677
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Fax |
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Provider Business Mailing Address
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Address Line | 391 17TH ST NW UNIT 3012
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City | ATLANTA
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State | GA
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Zip | 30363-1170
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Country | US
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Telephone | 419-344-4217
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | RPH032663
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License Number State | GA
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