Provider Demographics
NPI:1720650666
Name:OKWOYO, JERUSAH KWAMBOKA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JERUSAH
Middle Name:KWAMBOKA
Last Name:OKWOYO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8616 GULF DR APT B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-6621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3805 S KEYSTONE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-3540
Practice Address - Country:US
Practice Address - Phone:317-786-3485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26029143A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist