Provider Demographics
NPI:1790188282
Name:AMAMA, NDIFREKE
Entity Type:Individual
Prefix:
First Name:NDIFREKE
Middle Name:
Last Name:AMAMA
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 1:624 WALLEN HILLS DR APT 2
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-7061
Mailing Address - Country:US
Mailing Address - Phone:336-457-0850
Mailing Address - Fax:
Practice Address - Street 1:624 WALLEN HILLS DR APT 2
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-7061
Practice Address - Country:US
Practice Address - Phone:336-457-0850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26025795A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist