Provider Demographics
NPI:1336736883
Name:EVBAYEKHA, ALBERT OSARUMWENSE
Entity type:Individual
Prefix:
First Name:ALBERT
Middle Name:OSARUMWENSE
Last Name:EVBAYEKHA
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 1:12959 SW 21ST ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-2609
Mailing Address - Country:US
Mailing Address - Phone:305-962-0154
Mailing Address - Fax:
Practice Address - Street 1:6690 EAGLE NEST LN
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2264
Practice Address - Country:US
Practice Address - Phone:305-821-1402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS38159183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist