Provider Demographics
NPI:1760833883
Name:ADDO, EBENEZER
Entity Type:Individual
Prefix:
First Name:EBENEZER
Middle Name:
Last Name:ADDO
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 1:1725 TW ALEXANDER DR
Mailing Address - Street 2:UNIT 1503
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-9253
Mailing Address - Country:US
Mailing Address - Phone:910-581-4556
Mailing Address - Fax:
Practice Address - Street 1:1299 N BRIGHTLEAF BLVD
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-4229
Practice Address - Country:US
Practice Address - Phone:919-989-6655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22545183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist