Provider Demographics
NPI:1962797845
Name:EJUONEATSE, OMAWUMI BETSY
Entity type:Individual
Prefix:
First Name:OMAWUMI
Middle Name:BETSY
Last Name:EJUONEATSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3935 VENTURE DR
Mailing Address - Street 2:T-1779
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5078
Mailing Address - Country:US
Mailing Address - Phone:770-476-9656
Mailing Address - Fax:770-476-9656
Practice Address - Street 1:3935 VENTURE DR
Practice Address - Street 2:T-1779
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5078
Practice Address - Country:US
Practice Address - Phone:770-476-9656
Practice Address - Fax:770-476-9656
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-18
Last Update Date:2011-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023350183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist