Provider Demographics
NPI:1720074131
Name:BIVINS, GARY L (RPH)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:L
Last Name:BIVINS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3805 HEDGECLIFF CT
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-7116
Mailing Address - Country:US
Mailing Address - Phone:770-740-1810
Mailing Address - Fax:770-740-9371
Practice Address - Street 1:1000 JOHNSON FERRY RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1606
Practice Address - Country:US
Practice Address - Phone:404-851-6270
Practice Address - Fax:404-303-3323
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014009183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist