Provider Demographics
NPI:1568710143
Name:IBIAM-GRESHAM, UCHE (RPH)
Entity Type:Individual
Prefix:
First Name:UCHE
Middle Name:
Last Name:IBIAM-GRESHAM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CHARLOTTE CT
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31220-2665
Mailing Address - Country:US
Mailing Address - Phone:770-771-1441
Mailing Address - Fax:
Practice Address - Street 1:2423 US HIGHWAY 80 W
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-0930
Practice Address - Country:US
Practice Address - Phone:478-960-2662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023449183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist