Provider Demographics
NPI:1104395029
Name:KOUEMO, CHRISTELLE POUANI
Entity Type:Individual
Prefix:
First Name:CHRISTELLE
Middle Name:POUANI
Last Name:KOUEMO
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 1:9816 ROCKY FORD CLUB RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-2860
Mailing Address - Country:US
Mailing Address - Phone:704-773-7781
Mailing Address - Fax:
Practice Address - Street 1:9816 ROCKY FORD CLUB RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-2860
Practice Address - Country:US
Practice Address - Phone:704-773-7781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-20
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27954183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist