Healthcare Provider Details

I. General information

NPI: 1023681236
Provider Name (Legal Business Name): CHINOMSO OGBONNA, RICHARD OGBONNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2021
Last Update Date: 07/24/2021
Certification Date: 07/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6721 S CONGRESS AVE
AUSTIN TX
78745-5744
US

IV. Provider business mailing address

824 CAMINO LA COSTA
AUSTIN TX
78752-3865
US

V. Phone/Fax

Practice location:
  • Phone: 512-707-8245
  • Fax:
Mailing address:
  • Phone: 469-288-7849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number68507
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: