Provider Demographics
NPI:1174286561
Name:OBI, IHEZIE S (PHARMD)
Entity type:Individual
Prefix:
First Name:IHEZIE
Middle Name:S
Last Name:OBI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 HUSSON AVE APT 16
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3256
Mailing Address - Country:US
Mailing Address - Phone:240-475-9331
Mailing Address - Fax:
Practice Address - Street 1:34 MIDDLE STREET
Practice Address - Street 2:
Practice Address - City:EASTPORT
Practice Address - State:ME
Practice Address - Zip Code:04631
Practice Address - Country:US
Practice Address - Phone:207-853-9200
Practice Address - Fax:207-853-4002
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR69573183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist