Provider Demographics
NPI:1588264162
Name:SLACKS, COREY RICHARD
Entity type:Individual
Prefix:DR
First Name:COREY
Middle Name:RICHARD
Last Name:SLACKS
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 1:2404 CAVALIER XING
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-5325
Mailing Address - Country:US
Mailing Address - Phone:229-425-6058
Mailing Address - Fax:
Practice Address - Street 1:5401 FAIRINGTON RD
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-5113
Practice Address - Country:US
Practice Address - Phone:770-598-4998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-31
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH031069183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist