Provider Demographics
NPI:1881205771
Name:AGYEMAN, JUDE
Entity Type:Individual
Prefix:
First Name:JUDE
Middle Name:
Last Name:AGYEMAN
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 1:100 S PEACHTREE PKWY
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-1705
Mailing Address - Country:US
Mailing Address - Phone:770-487-4307
Mailing Address - Fax:770-487-9501
Practice Address - Street 1:100 S PEACHTREE PKWY
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-1705
Practice Address - Country:US
Practice Address - Phone:770-487-4307
Practice Address - Fax:770-487-9501
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH031765183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist