Provider Demographics
NPI:1518118900
Name:AGBALI, RAPHAEL AYEGBA (RPH)
Entity Type:Individual
Prefix:MR
First Name:RAPHAEL
Middle Name:AYEGBA
Last Name:AGBALI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 N ASHLEY ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-5912
Mailing Address - Country:US
Mailing Address - Phone:229-242-3007
Mailing Address - Fax:229-242-5831
Practice Address - Street 1:3200 N ASHLEY ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-5912
Practice Address - Country:US
Practice Address - Phone:229-242-3007
Practice Address - Fax:229-242-5831
Is Sole Proprietor?:No
Enumeration Date:2008-10-04
Last Update Date:2008-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA024485183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist