Provider Demographics
NPI:1124309661
Name:OKPALA, LONGINUS OKWUCHUKWU
Entity type:Individual
Prefix:
First Name:LONGINUS
Middle Name:OKWUCHUKWU
Last Name:OKPALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2384 MANAL WAY
Mailing Address - Street 2:2384 MANAL MANAL WAY
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-8170
Mailing Address - Country:US
Mailing Address - Phone:404-592-9639
Mailing Address - Fax:678-715-4973
Practice Address - Street 1:2384 MANAL WAY
Practice Address - Street 2:2384 MANAL MANAL WAY
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-8170
Practice Address - Country:US
Practice Address - Phone:404-592-9639
Practice Address - Fax:678-715-4973
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH022876183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist