Provider Demographics
NPI:1053922617
Name:ABABNEH, ROA A
Entity type:Individual
Prefix:
First Name:ROA A
Middle Name:
Last Name:ABABNEH
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 1:458 N BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-1606
Mailing Address - Country:US
Mailing Address - Phone:316-788-4317
Mailing Address - Fax:316-788-6859
Practice Address - Street 1:458 N BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-1606
Practice Address - Country:US
Practice Address - Phone:316-788-4317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-16
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-109974183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist