Provider Demographics
NPI:1790375657
Name:GARY, MITZI MATTHEWS
Entity Type:Individual
Prefix:
First Name:MITZI
Middle Name:MATTHEWS
Last Name:GARY
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 1:587 CHAPPELL RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-3039
Mailing Address - Country:US
Mailing Address - Phone:404-408-6851
Mailing Address - Fax:
Practice Address - Street 1:575 GLYNN ST N
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1198
Practice Address - Country:US
Practice Address - Phone:770-461-3911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-24
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH016530183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist