Provider Demographics
NPI:1083471817
Name:EZEMBA, EMMANUEL MBA
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:MBA
Last Name:EZEMBA
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 1:28 ACORN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902-3825
Mailing Address - Country:US
Mailing Address - Phone:781-254-3966
Mailing Address - Fax:
Practice Address - Street 1:300 CANAL ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-4558
Practice Address - Country:US
Practice Address - Phone:978-740-2912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA997226183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist