=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366266389
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NNANNA OKORAFOR
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2024
-----------------------------------------------------
Last Update Date | 11/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 SW WILSHIRE BLVD
-----------------------------------------------------
City | BURLESON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76028-4712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-295-1125
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4210 ANA RIDGE LN
-----------------------------------------------------
City | FULSHEAR
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77441-2303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-208-6178
-----------------------------------------------------
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 | 74792
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------