Provider Demographics
NPI:1912630625
Name:AGBOR-ENOH, RAPHAEL (RPH)
Entity Type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:
Last Name:AGBOR-ENOH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 TESTAVERDE RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-4558
Mailing Address - Country:US
Mailing Address - Phone:775-378-8673
Mailing Address - Fax:
Practice Address - Street 1:214 TESTAVERDE RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-4558
Practice Address - Country:US
Practice Address - Phone:775-378-8673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP455362183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist