Provider Demographics
NPI:1265929145
Name:AFANYU-LORATER, FABRICE (RPH)
Entity type:Individual
Prefix:
First Name:FABRICE
Middle Name:
Last Name:AFANYU-LORATER
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 1:103 MEDICINE WAY RD
Mailing Address - Street 2:
Mailing Address - City:PERIDOT
Mailing Address - State:AZ
Mailing Address - Zip Code:85542
Mailing Address - Country:US
Mailing Address - Phone:928-475-1300
Mailing Address - Fax:928-475-7376
Practice Address - Street 1:103 MEDICINE WAY RD
Practice Address - Street 2:
Practice Address - City:PERIDOT
Practice Address - State:AZ
Practice Address - Zip Code:85542
Practice Address - Country:US
Practice Address - Phone:928-475-1300
Practice Address - Fax:928-475-7376
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS0225501835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist