Healthcare Provider Details

I. General information

NPI: 1629672696
Provider Name (Legal Business Name): IKE OKOLI RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 W PIKE ST
LAWRENCEVILLE GA
30046-7699
US

IV. Provider business mailing address

11405 MABRYPARK PL
ALPHARETTA GA
30022-7361
US

V. Phone/Fax

Practice location:
  • Phone: 770-339-1801
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH025337
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: