=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912662974
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OSARETIN PEGGY OMOREGIE PHARM D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2021
-----------------------------------------------------
Last Update Date | 11/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4200 SALEM RD
-----------------------------------------------------
City | COVINGTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30016-4533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-212-3195
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 WOODBERRY PL
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30034-5548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-235-1727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | RPH032874
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------