=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558961805
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER BOURQUINE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2020
-----------------------------------------------------
Last Update Date | 10/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6995 CONCOURSE PKWY
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30134-4551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-489-3334
-----------------------------------------------------
Fax | 770-489-3616
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3005 SHADE TREE CT
-----------------------------------------------------
City | VILLA RICA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30180-6957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-456-4741
-----------------------------------------------------
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 | RPH016809
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------