Provider Demographics
NPI:1497105209
Name:ERUOTOR, AGHOGHO FRANCIS
Entity Type:Individual
Prefix:
First Name:AGHOGHO
Middle Name:FRANCIS
Last Name:ERUOTOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3811 78TH AVENUE CT W
Mailing Address - Street 2:APT J303
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-3259
Mailing Address - Country:US
Mailing Address - Phone:780-200-8650
Mailing Address - Fax:
Practice Address - Street 1:3840 BRIDGEPORT WAY W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4416
Practice Address - Country:US
Practice Address - Phone:253-564-2255
Practice Address - Fax:253-564-0189
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60643359183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist