Provider Demographics
NPI:1679351944
Name:ETTA, OBEN ENOW (RPH)
Entity Type:Individual
Prefix:DR
First Name:OBEN
Middle Name:ENOW
Last Name:ETTA
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 1:44 FANTASY LN APT E
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-6412
Mailing Address - Country:US
Mailing Address - Phone:617-901-9978
Mailing Address - Fax:
Practice Address - Street 1:522 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3432
Practice Address - Country:US
Practice Address - Phone:401-765-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32348183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist