Provider Demographics
NPI:1679037303
Name:YEBOAH, WADIE ABAYIE
Entity Type:Individual
Prefix:
First Name:WADIE
Middle Name:ABAYIE
Last Name:YEBOAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 N MAIN ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4406
Mailing Address - Country:US
Mailing Address - Phone:508-502-8656
Mailing Address - Fax:
Practice Address - Street 1:680 S STATE ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4913
Practice Address - Country:US
Practice Address - Phone:707-462-6850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80051183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist