Provider Demographics
NPI:1477238897
Name:EBANGHA, ATEM LUCY
Entity Type:Individual
Prefix:
First Name:ATEM
Middle Name:LUCY
Last Name:EBANGHA
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 1:200 GRAY TRL
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-7511
Mailing Address - Country:US
Mailing Address - Phone:651-354-6650
Mailing Address - Fax:
Practice Address - Street 1:129 MARIETTA HWY # 507273
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2304
Practice Address - Country:US
Practice Address - Phone:770-479-1806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034238183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist