Provider Demographics
NPI:1346022803
Name:AMEGBLETOR, CORNELIUS SENANU KWABLATSE (PHARMD)
Entity Type:Individual
Prefix:
First Name:CORNELIUS
Middle Name:SENANU KWABLATSE
Last Name:AMEGBLETOR
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2475 32ND AVE S STE 1
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-3606
Mailing Address - Country:US
Mailing Address - Phone:701-775-4209
Mailing Address - Fax:701-775-9122
Practice Address - Street 1:2475 32ND AVE S STE 1
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-3606
Practice Address - Country:US
Practice Address - Phone:701-775-4209
Practice Address - Fax:701-775-9122
Is Sole Proprietor?:No
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRPH6531183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist