Provider Demographics
NPI:1629786496
Name:KAMOUA, JABRA A (RPH)
Entity Type:Individual
Prefix:
First Name:JABRA
Middle Name:A
Last Name:KAMOUA
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 1:1601 W SYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612-1532
Mailing Address - Country:US
Mailing Address - Phone:419-246-7478
Mailing Address - Fax:419-470-0702
Practice Address - Street 1:1601 W SYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43612-1532
Practice Address - Country:US
Practice Address - Phone:419-246-7478
Practice Address - Fax:419-470-0702
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI03440325183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist