Provider Demographics
NPI:1427658384
Name:MOMIN, RAZIN
Entity type:Individual
Prefix:
First Name:RAZIN
Middle Name:
Last Name:MOMIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3743 WICKFORD LN
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CORNERS
Mailing Address - State:GA
Mailing Address - Zip Code:30096-2410
Mailing Address - Country:US
Mailing Address - Phone:678-575-7954
Mailing Address - Fax:
Practice Address - Street 1:1871 CHAMBLEE TUCKER RD
Practice Address - Street 2:
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341-2737
Practice Address - Country:US
Practice Address - Phone:770-455-4699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH026245183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist