Provider Demographics
NPI:1952932600
Name:WODAJO, AMANUEAL
Entity Type:Individual
Prefix:
First Name:AMANUEAL
Middle Name:
Last Name:WODAJO
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 1:457 NATHAN DEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-4911
Mailing Address - Country:US
Mailing Address - Phone:770-443-8776
Mailing Address - Fax:770-443-0653
Practice Address - Street 1:457 NATHAN DEAN BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-4911
Practice Address - Country:US
Practice Address - Phone:770-443-8776
Practice Address - Fax:770-443-0653
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0089441835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Multi-Specialty