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General NPI Number Information
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NPI Number | 1801134069
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Entity Type | Individual
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Provider Name | PATRICIA DIANE MORTIMER RPH
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Gender | Female
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Dates
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Enumeration Date | 01/23/2013
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Last Update Date | 12/22/2022
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Provider Practice Location Address
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Address Line | 101 PROMINENCE POINT PKWY
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City | CANTON
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State | GA
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Zip | 30114-9009
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Country | US
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Telephone | 770-704-4045
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Fax |
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Provider Business Mailing Address
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Address Line | 120 PROMINENCE POINT PKWY
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City | CANTON
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State | GA
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Zip | 30114-9008
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Country | US
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Telephone | 770-720-4825
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Fax | 770-720-4503
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 014397
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License Number State | GA
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