=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699347682
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SYNERGEN RX, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2021
-----------------------------------------------------
Last Update Date | 07/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3990 FLOWERS RD STE 530
-----------------------------------------------------
City | DORAVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30360-3195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-585-7517
-----------------------------------------------------
Fax | 404-900-9209
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3990 FLOWERS RD STE 530
-----------------------------------------------------
City | DORAVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30360-3195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-585-7517
-----------------------------------------------------
Fax | 404-900-9209
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP PHARMACY
-----------------------------------------------------
Name | JONATHAN PERSONIUS
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 404-585-7517
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------