Provider Demographics
NPI:1992534333
Name:KETEKU, EUGENE AFFUM
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:AFFUM
Last Name:KETEKU
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 1:145 FOREST BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-7878
Mailing Address - Country:US
Mailing Address - Phone:706-216-4225
Mailing Address - Fax:
Practice Address - Street 1:145 FOREST BLVD STE 100
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-7878
Practice Address - Country:US
Practice Address - Phone:706-216-4225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH035052183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist