Provider Demographics
NPI:1578861332
Name:GHANTA, ARCHANA
Entity Type:Individual
Prefix:
First Name:ARCHANA
Middle Name:
Last Name:GHANTA
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 1:3225 SAND HILL CT
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-5781
Mailing Address - Country:US
Mailing Address - Phone:770-888-5642
Mailing Address - Fax:
Practice Address - Street 1:51 HIGHWAY 400 S
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-6833
Practice Address - Country:US
Practice Address - Phone:706-216-2101
Practice Address - Fax:706-216-1303
Is Sole Proprietor?:No
Enumeration Date:2011-03-03
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH022473183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist