Provider Demographics
NPI:1740885516
Name:IBEH-KINGSLEY, VANESSA (PHARMD)
Entity type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:
Last Name:IBEH-KINGSLEY
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 1:1271 GRAY HWY
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31211-1919
Mailing Address - Country:US
Mailing Address - Phone:478-743-6979
Mailing Address - Fax:
Practice Address - Street 1:1271 GRAY HWY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31211-1919
Practice Address - Country:US
Practice Address - Phone:478-743-6979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH031778183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist