Provider Demographics
NPI:1558967679
Name:OPOKU, EVANS SEREBOUR (PHARM D)
Entity Type:Individual
Prefix:
First Name:EVANS
Middle Name:SEREBOUR
Last Name:OPOKU
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 FARM CREST DR APT 1B
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-8960
Mailing Address - Country:US
Mailing Address - Phone:574-952-0219
Mailing Address - Fax:
Practice Address - Street 1:1900 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-1046
Practice Address - Country:US
Practice Address - Phone:574-935-5697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-05
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051297820183500000X
TX64226183500000X
CA82469183500000X
IN26025605A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26025605AOtherINDIANA LICENSING AGENCY