Provider Demographics
NPI:1558560326
Name:GWINNETT CLINIC LTD
Entity type:Organization
Organization Name:GWINNETT CLINIC LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DEEP
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-995-3300
Mailing Address - Street 1:10600 MEDLOCK BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-8404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:475 PHILIP BLVD STE 101
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8737
Practice Address - Country:US
Practice Address - Phone:678-226-6212
Practice Address - Fax:678-225-4036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy