Provider Demographics
NPI:1104373901
Name:EZEDIKE, EMMANUEL
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:
Last Name:EZEDIKE
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 1:309 JOPPA CROSSING WAY
Mailing Address - Street 2:
Mailing Address - City:JOPPA
Mailing Address - State:MD
Mailing Address - Zip Code:21085-3742
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7651 HARFORD RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21234-6401
Practice Address - Country:US
Practice Address - Phone:410-444-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24402183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist