Provider Demographics
NPI:1487245759
Name:JUSTICE, GLORIA LE (PHARMD)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:LE
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 JONESBORO RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-3720
Mailing Address - Country:US
Mailing Address - Phone:678-583-5381
Mailing Address - Fax:
Practice Address - Street 1:204 JONESBORO RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-3720
Practice Address - Country:US
Practice Address - Phone:404-388-7789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28947183500000X
GARPH032058183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC28947OtherBOARD OF PHARMACY
GARPH032058OtherBOARD OF PHARMACY