Provider Demographics
NPI:1518242007
Name:OMENUKOR, JENNIFER CHIAZOKA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:CHIAZOKA
Last Name:OMENUKOR
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1170 CLIFTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-3435
Mailing Address - Country:US
Mailing Address - Phone:770-873-5478
Mailing Address - Fax:
Practice Address - Street 1:5511 CHAMBLEE DUNWOODY ROAD
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338
Practice Address - Country:US
Practice Address - Phone:770-671-9424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH026135183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH-026135OtherPHARMACIST LICENSE