Provider Demographics
NPI:1316639115
Name:SIDOROVA, TATYANA S
Entity type:Individual
Prefix:
First Name:TATYANA
Middle Name:S
Last Name:SIDOROVA
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 1:3925 PEACHTREE RD NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-5256
Mailing Address - Country:US
Mailing Address - Phone:470-639-4239
Mailing Address - Fax:
Practice Address - Street 1:3925 PEACHTREE RD NE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-5256
Practice Address - Country:US
Practice Address - Phone:470-639-4239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH034126183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist