Healthcare Provider Details

I. General information

NPI: 1417176751
Provider Name (Legal Business Name): ISAIAH ETUONU OKOH R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 01/24/2021
Certification Date: 01/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14820 MACK AVE RITE AID PHARMACY #7758
DETROIT MI
48215-2526
US

IV. Provider business mailing address

29048 GLOEDE DR APT. 1
WARREN MI
48088-4012
US

V. Phone/Fax

Practice location:
  • Phone: 313-331-1038
  • Fax:
Mailing address:
  • Phone: 586-585-9676
  • Fax: 586-585-9676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302037470
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: