Healthcare Provider Details

I. General information

NPI: 1568066363
Provider Name (Legal Business Name): MODESTA OBIAGELI OHAKWE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2020
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

895 HOLCOMB BRIDGE RD
ROSWELL GA
30076-1954
US

IV. Provider business mailing address

11092 LORIN WAY
JOHNS CREEK GA
30097-8482
US

V. Phone/Fax

Practice location:
  • Phone: 770-993-0194
  • Fax:
Mailing address:
  • Phone: 718-552-7988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number208707
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: