Provider Demographics
NPI:1336461243
Name:ANSAH, FIDELIS RONNY
Entity Type:Individual
Prefix:MR
First Name:FIDELIS
Middle Name:RONNY
Last Name:ANSAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10302 SUNRISE BLVD E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-8833
Mailing Address - Country:US
Mailing Address - Phone:253-604-1013
Mailing Address - Fax:253-604-1016
Practice Address - Street 1:10302 SUNRISE BLVD E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-8833
Practice Address - Country:US
Practice Address - Phone:253-604-1013
Practice Address - Fax:253-604-1016
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60018758183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist