Provider Demographics
NPI:1013517051
Name:EZEKWUECHE, CHIKELUE TAGBOO
Entity type:Individual
Prefix:
First Name:CHIKELUE
Middle Name:TAGBOO
Last Name:EZEKWUECHE
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 1:4105 ELDERS DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-9126
Mailing Address - Country:US
Mailing Address - Phone:706-832-9067
Mailing Address - Fax:
Practice Address - Street 1:3209 DEANS BRIDGE RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-4201
Practice Address - Country:US
Practice Address - Phone:706-796-7754
Practice Address - Fax:706-796-7818
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021838183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist