Healthcare Provider Details

I. General information

NPI: 1134842750
Provider Name (Legal Business Name): CHINEDUM DIKE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 GUADALUPE ST
LAREDO TX
78040-5252
US

IV. Provider business mailing address

709 GUADALUPE ST
LAREDO TX
78040-5252
US

V. Phone/Fax

Practice location:
  • Phone: 956-723-2911
  • Fax:
Mailing address:
  • Phone: 956-723-2911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number70921
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: