Provider Demographics
NPI:1831787571
Name:ARCHIBONG, GODFREY
Entity type:Individual
Prefix:DR
First Name:GODFREY
Middle Name:
Last Name:ARCHIBONG
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:GODFREY
Other - Middle Name:
Other - Last Name:ARCHIBONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD
Mailing Address - Street 1:747 E CLEVELAND CT
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-4282
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12409 N TATUM BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-7708
Practice Address - Country:US
Practice Address - Phone:602-996-7320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS022371183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist