Healthcare Provider Details

I. General information

NPI: 1922385947
Provider Name (Legal Business Name): NICHOLAS OKORONKWO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2011
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4520 WESTERN CENTER BLVD
HALTOM CITY TX
76137-2635
US

IV. Provider business mailing address

4520 WESTERN CENTER BLVD
HALTOM CITY TX
76137-2635
US

V. Phone/Fax

Practice location:
  • Phone: 817-514-8063
  • Fax: 817-514-9570
Mailing address:
  • Phone: 817-514-8063
  • Fax: 817-514-9570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number40445
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: