Provider Demographics
NPI:1437757804
Name:PARKS, KRISTA JERIANN (PHARMD)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:JERIANN
Last Name:PARKS
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 1:2700 BRASELTON HWY
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-3262
Mailing Address - Country:US
Mailing Address - Phone:770-614-1022
Mailing Address - Fax:770-614-4413
Practice Address - Street 1:2700 BRASELTON HWY
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-3262
Practice Address - Country:US
Practice Address - Phone:770-614-1022
Practice Address - Fax:770-614-4413
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH18799183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAKP4841Medicaid