=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508149659
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. LOUIS DIKENS ST JUSTE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2011
-----------------------------------------------------
Last Update Date | 12/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1556 LAWRENCEVILLE HWY
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30044-4601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-962-4946
-----------------------------------------------------
Fax | 770-962-0892
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2500 OLD NORCROSS RD
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30044-2100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-710-5434
-----------------------------------------------------
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 | RPH019770
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------