Provider Demographics
NPI:1639619307
Name:MEDICINAL PLUS
Entity Type:Organization
Organization Name:MEDICINAL PLUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LATASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:STALLWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:404-904-4282
Mailing Address - Street 1:2443 CENTER POINTE CIR SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-7309
Mailing Address - Country:US
Mailing Address - Phone:470-344-4696
Mailing Address - Fax:
Practice Address - Street 1:2443 CENTER POINTE CIR SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-7309
Practice Address - Country:US
Practice Address - Phone:470-344-4696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-28
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH26521314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility