=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639879000
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH SPADA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2023
-----------------------------------------------------
Last Update Date | 03/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 LOVERS LANE RD SE
-----------------------------------------------------
City | CALHOUN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30701-4871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-307-5052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1149 REGIMENT DR NW
-----------------------------------------------------
City | ACWORTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30101-8466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-823-9754
-----------------------------------------------------
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 | RPH030038
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------