Provider Demographics
NPI:1932789104
Name:ITEOGU, MICHAEL OGBENNA (RPH)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:OGBENNA
Last Name:ITEOGU
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 1:1169 FORSYTH ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-1735
Mailing Address - Country:US
Mailing Address - Phone:478-957-3370
Mailing Address - Fax:478-746-8362
Practice Address - Street 1:1377 PIO NONO AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-4633
Practice Address - Country:US
Practice Address - Phone:478-314-0021
Practice Address - Fax:478-742-1428
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH013513183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist