Provider Demographics
NPI:1871372342
Name:YACOUB, SHADI (PHARMD)
Entity type:Individual
Prefix:
First Name:SHADI
Middle Name:
Last Name:YACOUB
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 CHESHIRE BRIDGE RD NE UNIT 512
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-4281
Mailing Address - Country:US
Mailing Address - Phone:404-593-1743
Mailing Address - Fax:
Practice Address - Street 1:104 TOWN BLVD NE STE A100
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-3146
Practice Address - Country:US
Practice Address - Phone:404-233-7480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH034564183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist