Provider Demographics
NPI:1962000851
Name:OWUSU-BANAHENE, KWAME
Entity Type:Individual
Prefix:
First Name:KWAME
Middle Name:
Last Name:OWUSU-BANAHENE
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 1:4101 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:IL
Mailing Address - Zip Code:60534-1028
Mailing Address - Country:US
Mailing Address - Phone:708-447-6851
Mailing Address - Fax:
Practice Address - Street 1:4101 1ST AVE
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:IL
Practice Address - Zip Code:60534-1028
Practice Address - Country:US
Practice Address - Phone:708-447-6851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051299029183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist