Provider Demographics
NPI:1396213534
Name:HEPBURN, DAMALI AIDA (PHARMD)
Entity Type:Individual
Prefix:
First Name:DAMALI
Middle Name:AIDA
Last Name:HEPBURN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2465 KALEY WALK NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-2684
Mailing Address - Country:US
Mailing Address - Phone:770-714-4784
Mailing Address - Fax:
Practice Address - Street 1:2465 KALEY WALK NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-3015
Practice Address - Country:US
Practice Address - Phone:770-714-4784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202208696183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist