=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154824480
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELECHI COURAGE CHAVIS ONYIRIUKA PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2018
-----------------------------------------------------
Last Update Date | 07/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 SAMARITANS RIDGE CT STE 101
-----------------------------------------------------
City | ELKIN
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28621-2457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-226-8358
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3500 STONEHAVEN DR
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28215-3232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-226-8358
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 41721
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------