Provider Demographics
NPI:1316541683
Name:ONKISO, LOBE
Entity type:Individual
Prefix:
First Name:LOBE
Middle Name:
Last Name:ONKISO
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 1:4413 IDLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-6455
Mailing Address - Country:US
Mailing Address - Phone:206-397-6445
Mailing Address - Fax:
Practice Address - Street 1:911 SHORTER AVE SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-4164
Practice Address - Country:US
Practice Address - Phone:706-234-5331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-26
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH032366183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist