Healthcare Provider Details

I. General information

NPI: 1508628835
Provider Name (Legal Business Name): MARYMAGDALENE EYONGEGBE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2024
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 W PIONEER PKWY
GRAND PRAIRIE TX
75051-4708
US

IV. Provider business mailing address

16029 CHARING CROSS DR
JUSTIN TX
76247-1761
US

V. Phone/Fax

Practice location:
  • Phone: 972-641-5744
  • Fax: 972-641-0204
Mailing address:
  • Phone: 832-453-3117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number68542
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: