Provider Demographics
NPI:1386942993
Name:MANU, EBENEZER KOFI AMPOMAH
Entity type:Individual
Prefix:
First Name:EBENEZER
Middle Name:KOFI AMPOMAH
Last Name:MANU
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 1:3210 FAIRWAY CIR
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-1943
Mailing Address - Country:US
Mailing Address - Phone:954-607-8606
Mailing Address - Fax:
Practice Address - Street 1:3210 FAIRWAY CIR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-1943
Practice Address - Country:US
Practice Address - Phone:954-607-8606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-06
Last Update Date:2013-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0004035183500000X
FL45976183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist