Provider Demographics
NPI:1083050181
Name:LIVINUS, EDITH UCHE
Entity Type:Individual
Prefix:DR
First Name:EDITH
Middle Name:UCHE
Last Name:LIVINUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 MOSS CREEK WALK
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-2692
Mailing Address - Country:US
Mailing Address - Phone:404-246-2166
Mailing Address - Fax:
Practice Address - Street 1:773 HIGHWAY 138 SW
Practice Address - Street 2:SUITE 13
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-1599
Practice Address - Country:US
Practice Address - Phone:770-461-9015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH022522183500000X, 1835N1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835N1003XPharmacy Service ProvidersPharmacistNutrition Support