Provider Demographics
NPI:1417230707
Name:MOGBO, PATRICK NDIBE (PHARMD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:NDIBE
Last Name:MOGBO
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 1:1050 N KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2033
Mailing Address - Country:US
Mailing Address - Phone:815-932-9615
Mailing Address - Fax:815-932-9140
Practice Address - Street 1:1050 N KENNEDY DR
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2033
Practice Address - Country:US
Practice Address - Phone:815-932-9615
Practice Address - Fax:815-932-9140
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051293629183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist