Provider Demographics
NPI:1306346788
Name:COLLABORATIVERX
Entity type:Organization
Organization Name:COLLABORATIVERX
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:NAVEED
Authorized Official - Middle Name:
Authorized Official - Last Name:THARWANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-585-5445
Mailing Address - Street 1:311 GWINNETT DR STE 250
Mailing Address - Street 2:SUITE 250
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-5671
Mailing Address - Country:US
Mailing Address - Phone:404-585-5445
Mailing Address - Fax:678-498-6093
Practice Address - Street 1:311 GWINNETT DR STE 250
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-5671
Practice Address - Country:US
Practice Address - Phone:404-585-5445
Practice Address - Fax:678-498-6093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0104263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2175897OtherPK