Provider Demographics
NPI:1831473651
Name:GAUTAM, SMITHA
Entity Type:Individual
Prefix:
First Name:SMITHA
Middle Name:
Last Name:GAUTAM
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 1:2663 WINSLEY PL
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-3471
Mailing Address - Country:US
Mailing Address - Phone:812-962-4277
Mailing Address - Fax:
Practice Address - Street 1:599 S ENOTA DR NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2545
Practice Address - Country:US
Practice Address - Phone:770-536-4361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH025558183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist