Healthcare Provider Details

I. General information

NPI: 1215782636
Provider Name (Legal Business Name): DR. GRACE NSIKAN OKON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2024
Last Update Date: 04/19/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WALGREENS PHARMACY 8110 HIGHWAY 100
BELLEVUE TN
37221-4214
US

IV. Provider business mailing address

343 WOLF CREEK DR
WAXAHACHIE TX
75165-1658
US

V. Phone/Fax

Practice location:
  • Phone: 615-673-1251
  • Fax: 615-673-6489
Mailing address:
  • Phone: 218-206-0938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number70033
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number42711
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: