Provider Demographics
NPI:1669068144
Name:BONGADU-WALKER, JUDITH SULIY
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:SULIY
Last Name:BONGADU-WALKER
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 1:6065 JONESBORO RD
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-1168
Mailing Address - Country:US
Mailing Address - Phone:770-968-0660
Mailing Address - Fax:770-961-7964
Practice Address - Street 1:6065 JONESBORO RD
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-1168
Practice Address - Country:US
Practice Address - Phone:770-968-0660
Practice Address - Fax:770-961-7964
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH021898183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist