Provider Demographics
NPI:1225637077
Name:EJIGU, FREHIWOT
Entity Type:Individual
Prefix:
First Name:FREHIWOT
Middle Name:
Last Name:EJIGU
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 1:10705 EDDINGS DR APT 303
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-1205
Mailing Address - Country:US
Mailing Address - Phone:919-656-6860
Mailing Address - Fax:
Practice Address - Street 1:12311 N NC HIGHWAY 150
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-9730
Practice Address - Country:US
Practice Address - Phone:336-764-2581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29961183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist