=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972197515
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES A PLATZ R.PH.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2021
-----------------------------------------------------
Last Update Date | 02/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3070 BUSINESS PARK DR STE A
-----------------------------------------------------
City | NORCROSS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30071-1428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-496-5314
-----------------------------------------------------
Fax | 770-496-7445
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2078
-----------------------------------------------------
City | FLOWERY BRANCH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30542-0035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-375-6819
-----------------------------------------------------
Fax | 770-496-7445
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | RPH0013450
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------