=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699175562
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. KEROP B GOURDIKIAN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2014
-----------------------------------------------------
Last Update Date | 03/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3505 CENTERVILLE HWY
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30039-6405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-736-2157
-----------------------------------------------------
Fax | 770-736-9340
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2605 HAMILTON MILL RD
-----------------------------------------------------
City | BUFORD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30519-4106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-546-5352
-----------------------------------------------------
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 | 15738
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------