Provider Demographics
NPI:1801129002
Name:ANANE - ANSAH, IGNATIUS
Entity type:Individual
Prefix:
First Name:IGNATIUS
Middle Name:
Last Name:ANANE - ANSAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-4528
Mailing Address - Country:US
Mailing Address - Phone:704-906-0787
Mailing Address - Fax:
Practice Address - Street 1:1415 N WENDOVER RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-7129
Practice Address - Country:US
Practice Address - Phone:704-332-9081
Practice Address - Fax:704-332-8621
Is Sole Proprietor?:No
Enumeration Date:2009-09-07
Last Update Date:2009-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18528183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0609040Medicaid