Provider Demographics
NPI:1891140513
Name:ENTSIWAH, EDWARD BRAYE (RPH)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:BRAYE
Last Name:ENTSIWAH
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 1:48 BENTON ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4304
Mailing Address - Country:US
Mailing Address - Phone:860-796-2004
Mailing Address - Fax:
Practice Address - Street 1:48 BENTON ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4304
Practice Address - Country:US
Practice Address - Phone:860-796-2004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-01
Last Update Date:2016-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9402183500000X
MA24379183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist