Basic Information
| Provider Information | |||||||||
| NPI: | 1073699286 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATLANTA VA MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1112 DOVE VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300322322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042840782 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1670 CLAIRMONT RD | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300334004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043216111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | MELVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINICAL PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 4043216111 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | RPH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QV0200X | 19217 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | VA |
No ID Information.