Provider Demographics
NPI:1346844461
Name:IFEADIKE, NKASIOBI
Entity Type:Individual
Prefix:
First Name:NKASIOBI
Middle Name:
Last Name:IFEADIKE
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 1:1160 CHAPEL ESTATES WAY
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-2702
Mailing Address - Country:US
Mailing Address - Phone:404-510-6792
Mailing Address - Fax:
Practice Address - Street 1:4377 ATLANTA HWY
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-2642
Practice Address - Country:US
Practice Address - Phone:770-466-0109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH032257183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist