Provider Demographics
NPI:1467701128
Name:ADDO, NANA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:NANA
Middle Name:
Last Name:ADDO
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 1:2497 AUTUMN MIST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5543
Mailing Address - Country:US
Mailing Address - Phone:804-319-7347
Mailing Address - Fax:
Practice Address - Street 1:855 HANES MALL BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-5526
Practice Address - Country:US
Practice Address - Phone:336-768-2888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-09
Last Update Date:2012-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22062183500000X
VA0202211711183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0202211711OtherVIRGINA BOARD OF PHARMACY LICENSE
NC22062OtherNC BOARD OF PHARMACY LICENSE