Healthcare Provider Details

I. General information

NPI: 1265952329
Provider Name (Legal Business Name): DR. CHIBUGO EJISOBY-NWOSU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 06/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2994 ATLANTA RD SE
SMYRNA GA
30080-3655
US

IV. Provider business mailing address

1284 GLANDOR CT SE
MABLETON GA
30126-2755
US

V. Phone/Fax

Practice location:
  • Phone: 770-435-2178
  • Fax:
Mailing address:
  • Phone: 678-230-3089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number019518
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number019518
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: