Healthcare Provider Details

I. General information

NPI: 1104167170
Provider Name (Legal Business Name): OBINNA EZEKWE PHARM.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2013
Last Update Date: 03/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14139 POTOMAC MILLS RD
WOODBRIDGE VA
22192-4644
US

IV. Provider business mailing address

15318 GUNSMITH TER
WOODBRIDGE VA
22191-3926
US

V. Phone/Fax

Practice location:
  • Phone: 703-490-8400
  • Fax:
Mailing address:
  • Phone: 703-680-5969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202206168
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: