Provider Demographics
NPI:1912664582
Name:MABATAH, INNOCENT OKAFOR
Entity Type:Individual
Prefix:
First Name:INNOCENT
Middle Name:OKAFOR
Last Name:MABATAH
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 1:1719 BRICE RD
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-2705
Mailing Address - Country:US
Mailing Address - Phone:614-501-4410
Mailing Address - Fax:614-501-4430
Practice Address - Street 1:1719 BRICE RD
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-2705
Practice Address - Country:US
Practice Address - Phone:614-501-4410
Practice Address - Fax:614-501-4430
Is Sole Proprietor?:No
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03334336183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist