Healthcare Provider Details

I. General information

NPI: 1720650666
Provider Name (Legal Business Name): JERUSAH KWAMBOKA OKWOYO PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 S KEYSTONE AVE
INDIANAPOLIS IN
46227-3540
US

IV. Provider business mailing address

8616 GULF DR APT B
FORT WAYNE IN
46825-6621
US

V. Phone/Fax

Practice location:
  • Phone: 317-786-3485
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26029143A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: