Provider Demographics
NPI:1720533227
Name:ANUGERAH, ANASTASIA
Entity type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:
Last Name:ANUGERAH
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 1:2774 N COBB PKWY STE 201
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-3469
Mailing Address - Country:US
Mailing Address - Phone:770-426-3246
Mailing Address - Fax:
Practice Address - Street 1:2774 N COBB PKWY STE 201
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-3469
Practice Address - Country:US
Practice Address - Phone:770-426-3246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH029335183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist