Provider Demographics
NPI:1750079125
Name:GONDER, IESHA RANAE
Entity type:Individual
Prefix:
First Name:IESHA
Middle Name:RANAE
Last Name:GONDER
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 1:206 LONG LEAF WAY
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-1680
Mailing Address - Country:US
Mailing Address - Phone:478-595-0913
Mailing Address - Fax:
Practice Address - Street 1:2320 N DRUID HILLS RD NE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-3109
Practice Address - Country:US
Practice Address - Phone:404-248-1793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-25
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH033917183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist