Provider Demographics
NPI:1770022634
Name:AHENKORA, JULIET
Entity Type:Individual
Prefix:
First Name:JULIET
Middle Name:
Last Name:AHENKORA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9218 MCCARTY RD
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-2924
Mailing Address - Country:US
Mailing Address - Phone:571-490-6633
Mailing Address - Fax:
Practice Address - Street 1:2701 S CEDAR ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-3028
Practice Address - Country:US
Practice Address - Phone:571-490-6633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302045203183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302045203Medicaid
MI5302045203Medicare PIN
MI5302045203Medicaid
MI5302045203Medicare Oscar/Certification
MI5302045203Medicare UPIN