Provider Demographics
NPI:1881129450
Name:AMONOO, EBENEZER
Entity type:Individual
Prefix:
First Name:EBENEZER
Middle Name:
Last Name:AMONOO
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 1:161 EINSTEIN LOOP
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-4902
Mailing Address - Country:US
Mailing Address - Phone:718-708-8171
Mailing Address - Fax:718-708-8172
Practice Address - Street 1:161 EINSTEIN LOOP
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-4902
Practice Address - Country:US
Practice Address - Phone:718-708-8171
Practice Address - Fax:718-708-8172
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT. 0011454183500000X
NY057911183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist