Healthcare Provider Details

I. General information

NPI: 1255613162
Provider Name (Legal Business Name): NWAMAKA VIVIAN OKONKWO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2011
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2065 S HAIRSTON RD
DECATUR GA
30035-2504
US

IV. Provider business mailing address

3551 HEDGESTONE LN
SNELLVILLE GA
30078-8810
US

V. Phone/Fax

Practice location:
  • Phone: 770-322-1290
  • Fax: 770-323-0333
Mailing address:
  • Phone: 678-516-1804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH022731
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: