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General NPI Number Information
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NPI Number | 1184264384
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Entity Type | Individual
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Provider Name | JOHN ETAKIBUEBU PHARMD
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Gender | Male
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Dates
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Enumeration Date | 01/15/2020
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Last Update Date | 01/15/2020
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Provider Practice Location Address
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Address Line | 2415 HWY 79 S
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City | HENDERSON
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State | TX
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Zip | 75652
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Country | US
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Telephone | 903-657-8596
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Fax |
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Provider Business Mailing Address
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Address Line | 2415 HWY 79 S
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City | HENDERSON
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State | TX
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Zip | 75652
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Country | US
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Telephone | 903-657-8596
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1835P0018X
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Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
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License Number | 54248
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License Number State | TX
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