Provider Demographics
NPI:1215326707
Name:TANENBAUM, GAYLE M (BS, RPH)
Entity type:Individual
Prefix:
First Name:GAYLE
Middle Name:M
Last Name:TANENBAUM
Suffix:
Gender:F
Credentials:BS, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 BULLOCH LAKE CT
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-8649
Mailing Address - Country:US
Mailing Address - Phone:770-554-1429
Mailing Address - Fax:770-544-0929
Practice Address - Street 1:1401 BULLOCH LAKE CT
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-8649
Practice Address - Country:US
Practice Address - Phone:770-554-1429
Practice Address - Fax:770-544-0929
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH0221601835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH022160OtherPHARMACIST LICENSE