Provider Demographics
NPI:1467908640
Name:EZEASOR, CHIBUIKEM HENRY (PHARMD)
Entity Type:Individual
Prefix:
First Name:CHIBUIKEM
Middle Name:HENRY
Last Name:EZEASOR
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 1:215 BROOKESTONE PT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-8241
Mailing Address - Country:US
Mailing Address - Phone:678-860-1129
Mailing Address - Fax:
Practice Address - Street 1:215 BROOKESTONE PT
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-8241
Practice Address - Country:US
Practice Address - Phone:678-860-1129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH029272183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist