=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669078283
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEX PERRYMAN PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2020
-----------------------------------------------------
Last Update Date | 12/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22 UPPER RIVERDALE RD SE
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30274-2620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-472-4566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4491 JOHN WESLEY DR
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30035-2149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-732-1086
-----------------------------------------------------
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 | RPH030913
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------