Provider Demographics
NPI:1255613162
Name:OKONKWO, NWAMAKA VIVIAN
Entity type:Individual
Prefix:
First Name:NWAMAKA
Middle Name:VIVIAN
Last Name:OKONKWO
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 1:3551 HEDGESTONE LN
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-8810
Mailing Address - Country:US
Mailing Address - Phone:678-516-1804
Mailing Address - Fax:
Practice Address - Street 1:2065 S HAIRSTON RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-2504
Practice Address - Country:US
Practice Address - Phone:770-322-1290
Practice Address - Fax:770-323-0333
Is Sole Proprietor?:No
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH022731183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist