Provider Demographics
NPI:1679256382
Name:BODKIN, ZACHARY JON
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:JON
Last Name:BODKIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4391 ACWORTH DALLAS RD NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-4334
Mailing Address - Country:US
Mailing Address - Phone:770-370-2235
Mailing Address - Fax:770-370-2236
Practice Address - Street 1:4391 ACWORTH DALLAS RD NW STE 200
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-4335
Practice Address - Country:US
Practice Address - Phone:770-370-2235
Practice Address - Fax:770-370-2236
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHTC050529183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician