Provider Demographics
NPI:1902409279
Name:ROGERS, ALEXIS SHANTEL
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:SHANTEL
Last Name:ROGERS
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 1:5415 N HENRY BLVD
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-3222
Mailing Address - Country:US
Mailing Address - Phone:662-231-7449
Mailing Address - Fax:
Practice Address - Street 1:5415 N HENRY BLVD
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-3222
Practice Address - Country:US
Practice Address - Phone:662-231-7449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH031098183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty