Provider Demographics
NPI:1922551357
Name:KOLI, MICA INGE (RPH PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MICA
Middle Name:INGE
Last Name:KOLI
Suffix:
Gender:F
Credentials:RPH PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6055 MILLWICK DR
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30005-6743
Mailing Address - Country:US
Mailing Address - Phone:678-620-9356
Mailing Address - Fax:
Practice Address - Street 1:6055 MILLWICK DR
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30005-6743
Practice Address - Country:US
Practice Address - Phone:678-620-9356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH016505183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH016505OtherPHARMACIST
GA430715OtherNABP