Provider Demographics
NPI:1174846471
Name:OBOGBAIMHE, OMORHO
Entity Type:Individual
Prefix:
First Name:OMORHO
Middle Name:
Last Name:OBOGBAIMHE
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 1:263 N CORONA AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-4124
Mailing Address - Country:US
Mailing Address - Phone:516-887-3739
Mailing Address - Fax:
Practice Address - Street 1:263 N CORONA AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-4124
Practice Address - Country:US
Practice Address - Phone:516-887-3739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-01
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051994-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist