Provider Demographics
NPI:1326641309
Name:ANDOH, KHADIJAH ADOMA
Entity Type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:ADOMA
Last Name:ANDOH
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 1:221 E LAKE AVE # C205
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-2258
Mailing Address - Country:US
Mailing Address - Phone:913-439-0730
Mailing Address - Fax:
Practice Address - Street 1:300 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:WALKERTON
Practice Address - State:IN
Practice Address - Zip Code:46574-1246
Practice Address - Country:US
Practice Address - Phone:574-586-7154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26028655A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty