Provider Demographics
NPI:1255331617
Name:PRIVETTE, PAMELA R (RPH,MS)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:R
Last Name:PRIVETTE
Suffix:
Gender:F
Credentials:RPH,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 MOCKINGBIRD LN
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1160
Mailing Address - Country:US
Mailing Address - Phone:404-378-5663
Mailing Address - Fax:
Practice Address - Street 1:1000 JOHNSON FERRY RD NE
Practice Address - Street 2:NORTHSIDE HOSPITAL PHARMACY
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1606
Practice Address - Country:US
Practice Address - Phone:404-851-8123
Practice Address - Fax:404-303-3898
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA13737183500000X
SC4494183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist