=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447531702
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PRIYABEN S MEHTA PHARM. D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2011
-----------------------------------------------------
Last Update Date | 08/31/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1510 MILSTEAD AVE NE
-----------------------------------------------------
City | CONYERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30012-8030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-785-7128
-----------------------------------------------------
Fax | 770-785-7257
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1545 NATCHEZ WAY
-----------------------------------------------------
City | GRAYSON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30017-2930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-472-4275
-----------------------------------------------------
Fax | 770-785-7257
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RPH023339
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------