Provider Demographics
NPI:1316547557
Name:DILLARD, JACI MICHELLE
Entity Type:Individual
Prefix:
First Name:JACI
Middle Name:MICHELLE
Last Name:DILLARD
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 1:1269 MACKINTOSH PARK NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-4177
Mailing Address - Country:US
Mailing Address - Phone:770-851-7880
Mailing Address - Fax:
Practice Address - Street 1:3615 CHARLES HARDY PKWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-9472
Practice Address - Country:US
Practice Address - Phone:770-445-9096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH02422183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist