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General NPI Number Information
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NPI Number | 1942436027
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Entity Type | Organization
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Legal Business Name | PROVIDENCE PHARMACY INC
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Dates
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Enumeration Date | 06/03/2009
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Last Update Date | 03/11/2021
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Provider Practice Location Address
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Address Line | 180 W BROAD ST STE A
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City | FAIRBURN
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State | GA
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Zip | 30213
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Country | US
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Telephone | 678-489-2069
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Fax | 678-489-8627
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Provider Business Mailing Address
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Address Line | 180 W BROAD ST STE A
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City | FAIRBURN
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State | GA
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Zip | 30213
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Country | US
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Telephone | 678-489-2069
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Fax | 678-489-8627
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Authorized Official
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Title or Position | CEO
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Name | CLEMENT EMEKA OKPALA
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Credential | PHARMD
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Telephone | 678-489-2069
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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