Provider Demographics
NPI:1881974376
Name:IGBINOWANHIA, MOND U
Entity type:Individual
Prefix:
First Name:MOND
Middle Name:U
Last Name:IGBINOWANHIA
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 1:4564 GLORE CROSSING DR SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-5551
Mailing Address - Country:US
Mailing Address - Phone:404-402-0073
Mailing Address - Fax:
Practice Address - Street 1:855 VETERANS MEMORIAL HWY SE
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-2733
Practice Address - Country:US
Practice Address - Phone:770-819-7869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-28
Last Update Date:2011-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH018602183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist