Provider Demographics
NPI:1366740987
Name:MISHRA, HETAL
Entity type:Individual
Prefix:
First Name:HETAL
Middle Name:
Last Name:MISHRA
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 1:1020 WINDHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-2209
Mailing Address - Country:US
Mailing Address - Phone:404-931-4594
Mailing Address - Fax:
Practice Address - Street 1:4830 HIGHWAY 9 N
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-2975
Practice Address - Country:US
Practice Address - Phone:770-777-0589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-06
Last Update Date:2011-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH022476183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist