Provider Demographics
NPI:1417628348
Name:TIJU, BETCY
Entity Type:Individual
Prefix:
First Name:BETCY
Middle Name:
Last Name:TIJU
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 1:831 AUBURN RD
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-5434
Mailing Address - Country:US
Mailing Address - Phone:770-682-2627
Mailing Address - Fax:
Practice Address - Street 1:831 AUBURN RD
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-5434
Practice Address - Country:US
Practice Address - Phone:770-682-2627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-21
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH033265183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist