Provider Demographics
NPI:1588672620
Name:NYOTA
Entity Type:Organization
Organization Name:NYOTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THADDEUS
Authorized Official - Middle Name:ALTONIO
Authorized Official - Last Name:BLUE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:678-933-1711
Mailing Address - Street 1:58 FLAT SHOALS AVE SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-1337
Mailing Address - Country:US
Mailing Address - Phone:404-399-5124
Mailing Address - Fax:
Practice Address - Street 1:58 FLAT SHOALS AVE SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-1337
Practice Address - Country:US
Practice Address - Phone:404-399-5124
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019367183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty