Healthcare Provider Details

I. General information

NPI: 1679782999
Provider Name (Legal Business Name): SONY ANDREW OBUSEH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3345 PINEVILLE MATTHEWS RD
CHARLOTTE NC
28226-9304
US

IV. Provider business mailing address

820 WHEATFIELD DR
WAXHAW NC
28173
US

V. Phone/Fax

Practice location:
  • Phone: 704-543-6055
  • Fax: 704-544-9997
Mailing address:
  • Phone: 704-243-1202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number15394
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: