Healthcare Provider Details

I. General information

NPI: 1497306427
Provider Name (Legal Business Name): IJEOMA EZINNE ONYEMA PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5180
US

IV. Provider business mailing address

5320 SAN MATEO BLVD NE APT A16
ALBUQUERQUE NM
87109-6201
US

V. Phone/Fax

Practice location:
  • Phone: 505-256-1711
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License Number2018025583
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: