=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265038517
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NGOZI KOKO OKORIE RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2020
-----------------------------------------------------
Last Update Date | 12/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 N WALNUT CREEK DR
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063-2502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-473-0271
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 612 FAWN MEADOW TRL
-----------------------------------------------------
City | KENNEDALE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76060-5837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-478-7309
-----------------------------------------------------
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 | 35694
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------