Provider Demographics
NPI:1023372497
Name:ACHONDUH, KISSITA INGABOU
Entity type:Individual
Prefix:
First Name:KISSITA
Middle Name:INGABOU
Last Name:ACHONDUH
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 1:6502 GRAINGER TER
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-4835
Mailing Address - Country:US
Mailing Address - Phone:240-645-3731
Mailing Address - Fax:
Practice Address - Street 1:6001 HIGH BRIDGE RD
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-5205
Practice Address - Country:US
Practice Address - Phone:301-262-4956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-29
Last Update Date:2024-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD28347183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist