Healthcare Provider Details

I. General information

NPI: 1114352184
Provider Name (Legal Business Name): KENNETH C OKWUNWANNE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2013
Last Update Date: 09/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 BATAAN MEMORIAL E
LAS CRUCES NM
88011-6011
US

IV. Provider business mailing address

596 PAT CRUZ
EL PASO TX
79932-4107
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-8603
  • Fax:
Mailing address:
  • Phone: 915-261-9713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00005662
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number31267
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: