MEDICARE: MODESTA OBIAGELI OHAKWE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	208707	GA

General Provider Information

NPI Number	:	1568066363
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MODESTA OBIAGELI OHAKWE

Provider Business Mailing Address
First Line	:	11092 LORIN WAY
Second Line	:
City	:	JOHNS CREEK
State	:	GA
Zip	:	30097-8482
Country	:	US
Telephone Number	:	718-552-7988
Fax Number	:

Provider Business Practice Location Address
First Line	:	895 HOLCOMB BRIDGE RD
Second Line	:
City	:	ROSWELL
State	:	GA
Zip	:	30076-1954
Country	:	US
Telephone Number	:	770-993-0194
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/23/2020
Last Update Date	:	11/23/2020

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