Provider Demographics
NPI:1598368896
Name:LAWSON-BODY, LATE MADJE (RPH)
Entity Type:Individual
Prefix:
First Name:LATE
Middle Name:MADJE
Last Name:LAWSON-BODY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 UPPER RIVERDALE RD SE
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2620
Mailing Address - Country:US
Mailing Address - Phone:770-472-4566
Mailing Address - Fax:
Practice Address - Street 1:22 UPPER RIVERDALE RD SE
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2620
Practice Address - Country:US
Practice Address - Phone:770-472-4566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH028140183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty