Provider Demographics
NPI:1851638761
Name:MAURIELLO, TABATHA LAMBERT
Entity Type:Individual
Prefix:
First Name:TABATHA
Middle Name:LAMBERT
Last Name:MAURIELLO
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 1:931 LOWER FAYETTEVILLE RD
Mailing Address - Street 2:SUITE K
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-5790
Mailing Address - Country:US
Mailing Address - Phone:770-502-7055
Mailing Address - Fax:770-502-7054
Practice Address - Street 1:931 LOWER FAYETTEVILLE RD
Practice Address - Street 2:SUITE K
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-5790
Practice Address - Country:US
Practice Address - Phone:770-502-7055
Practice Address - Fax:770-502-7054
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH021368183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist