Healthcare Provider Details

I. General information

NPI: 1659689743
Provider Name (Legal Business Name): IJEOMA OBINWANNE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2010
Last Update Date: 08/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10808 RAMONA BLVD
EL MONTE CA
91731-2628
US

IV. Provider business mailing address

10808 RAMONA BLVD
EL MONTE CA
91731-2628
US

V. Phone/Fax

Practice location:
  • Phone: 626-579-6277
  • Fax: 626-579-6739
Mailing address:
  • Phone: 626-579-6277
  • Fax: 626-579-6739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY50449
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: IJEOMA OBINWANNE
Title or Position: PHARMACIST
Credential:
Phone: 626-579-6277