Provider Demographics
NPI:1477182012
Name:ODIMGBE, CHIZOBA
Entity Type:Individual
Prefix:
First Name:CHIZOBA
Middle Name:
Last Name:ODIMGBE
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 1:18 RAINTREE WAY
Mailing Address - Street 2:
Mailing Address - City:PORT WENTWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:31407-3605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18 RAINTREE WAY
Practice Address - Street 2:
Practice Address - City:PORT WENTWORTH
Practice Address - State:GA
Practice Address - Zip Code:31407-3605
Practice Address - Country:US
Practice Address - Phone:912-237-1681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-06
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH030626183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH030626OtherGEORGIA BOARD OF PHARMACY