Provider Demographics
NPI:1346844164
Name:TETSADJIO, IDRISSE B (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:IDRISSE
Middle Name:B
Last Name:TETSADJIO
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:IDRISSE
Other - Middle Name:B
Other - Last Name:TETSADJIO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:581 FLINT RIVER RD
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-4519
Mailing Address - Country:US
Mailing Address - Phone:770-603-2044
Mailing Address - Fax:
Practice Address - Street 1:581 FLINT RIVER RD
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-4519
Practice Address - Country:US
Practice Address - Phone:770-603-2044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031135183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist