=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952907628
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ONKEMETSE PHILLIP KIBITWE PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2020
-----------------------------------------------------
Last Update Date | 12/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12907 E JEFFERSON AVE
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48215-2751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-926-8918
-----------------------------------------------------
Fax | 313-822-2019
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12907 E JEFFERSON AVE
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48215-2751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-926-8918
-----------------------------------------------------
Fax | 313-822-2019
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5302033057
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------