Provider Demographics
NPI:1568066363
Name:OHAKWE, MODESTA OBIAGELI
Entity Type:Individual
Prefix:
First Name:MODESTA
Middle Name:OBIAGELI
Last Name:OHAKWE
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 1:11092 LORIN WAY
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-8482
Mailing Address - Country:US
Mailing Address - Phone:718-552-7988
Mailing Address - Fax:
Practice Address - Street 1:895 HOLCOMB BRIDGE RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1954
Practice Address - Country:US
Practice Address - Phone:770-993-0194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA208707183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty