Healthcare Provider Details

I. General information

NPI: 1154592178
Provider Name (Legal Business Name): HELEN IYAIBIBOIMA ABERE RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2008
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 FAIRVIEW RD
ELLENWOOD GA
30294-2722
US

IV. Provider business mailing address

101 FAIRVIEW RD
ELLENWOOD GA
30294-2722
US

V. Phone/Fax

Practice location:
  • Phone: 770-389-7088
  • Fax: 770-507-5402
Mailing address:
  • Phone: 770-389-7088
  • Fax: 770-507-5402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number017919
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number017919
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: