Provider Demographics
NPI:1275133605
Name:ANIZOBA, NNEKA NICKY (RPH)
Entity Type:Individual
Prefix:DR
First Name:NNEKA
Middle Name:NICKY
Last Name:ANIZOBA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10404 MONARCH RD UNIT 4
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-8876
Mailing Address - Country:US
Mailing Address - Phone:773-510-6006
Mailing Address - Fax:
Practice Address - Street 1:3902 W RIVERSIDE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101-9507
Practice Address - Country:US
Practice Address - Phone:815-962-4071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.302511183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist