Provider Demographics
NPI:1093097222
Name:THAKKOLKARAN, SOUMIA
Entity Type:Individual
Prefix:
First Name:SOUMIA
Middle Name:
Last Name:THAKKOLKARAN
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 1:2365 BUFORD DR
Mailing Address - Street 2:WALGREENS 6088
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043
Mailing Address - Country:US
Mailing Address - Phone:404-543-8431
Mailing Address - Fax:
Practice Address - Street 1:2365 BUFORD DR
Practice Address - Street 2:WALGREENS 6088
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-2609
Practice Address - Country:US
Practice Address - Phone:404-543-8431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH026259183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist