Provider Demographics
NPI:1720325590
Name:IRWIN, ROBERT WILLIAM
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:WILLIAM
Last Name:IRWIN
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 1:295 SAGEGLEN RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-5249
Mailing Address - Country:US
Mailing Address - Phone:404-580-8575
Mailing Address - Fax:
Practice Address - Street 1:380 N DESHON RD
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-4797
Practice Address - Country:US
Practice Address - Phone:770-879-2706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-13
Last Update Date:2013-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH012587183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist