Healthcare Provider Details

I. General information

NPI: 1194152835
Provider Name (Legal Business Name): SAMPSON NNADI OGBUCHI-SANTANA JR. PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2013
Last Update Date: 09/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6205 WESTCREEK DR
FORT WORTH TX
76133-4319
US

IV. Provider business mailing address

5512 GREENWOOD CREEK DR APT 428
BENBROOK TX
76109-3992
US

V. Phone/Fax

Practice location:
  • Phone: 817-263-0962
  • Fax:
Mailing address:
  • Phone: 504-729-7075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number52810
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number020069
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: