Provider Demographics
NPI:1255086880
Name:IYOHA, ADAEZE JULIET
Entity type:Individual
Prefix:
First Name:ADAEZE
Middle Name:JULIET
Last Name:IYOHA
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 1:1465 LATITUDES WAY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-4509
Mailing Address - Country:US
Mailing Address - Phone:734-589-5092
Mailing Address - Fax:
Practice Address - Street 1:880 SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-1914
Practice Address - Country:US
Practice Address - Phone:415-456-4442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85585183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA85585OtherRPH LICENSE