Provider Demographics
NPI:1861492282
Name:BINGHAM, JAELYN L (RPH)
Entity Type:Individual
Prefix:MRS
First Name:JAELYN
Middle Name:L
Last Name:BINGHAM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4678 THREE SPRINGS CT
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-6351
Mailing Address - Country:US
Mailing Address - Phone:770-518-5622
Mailing Address - Fax:404-851-8610
Practice Address - Street 1:1000 JOHNSON FERRY RD NE
Practice Address - Street 2:NORTHSIDE HOSPITAL PHARMACY
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1606
Practice Address - Country:US
Practice Address - Phone:404-303-3519
Practice Address - Fax:404-851-8610
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH018691183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist