Provider Demographics
NPI:1174805485
Name:CASASOLA, SIMY
Entity type:Individual
Prefix:
First Name:SIMY
Middle Name:
Last Name:CASASOLA
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 1:2990 FIVE FORKS TRICKUM RD
Mailing Address - Street 2:WALGREENS PHARMACY # 05446
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044
Mailing Address - Country:US
Mailing Address - Phone:770-978-6475
Mailing Address - Fax:770-978-0369
Practice Address - Street 1:2990 FIVE FORKS TRICKUM RD
Practice Address - Street 2:WALGREENS #05446
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044
Practice Address - Country:US
Practice Address - Phone:770-978-6475
Practice Address - Fax:770-978-0369
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023123183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist