Provider Demographics
NPI:1912475559
Name:JUSU, THOMAS SAO (RPH)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:SAO
Last Name:JUSU
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 1:4141 BROOKS MILL DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-4144
Mailing Address - Country:US
Mailing Address - Phone:678-357-1044
Mailing Address - Fax:
Practice Address - Street 1:1308 GLENWOOD AVE SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-2077
Practice Address - Country:US
Practice Address - Phone:404-968-9332
Practice Address - Fax:404-968-9856
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH019123183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist