=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427360403
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. IHEANACHO AHAMEFULA EZIRIM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2010
-----------------------------------------------------
Last Update Date | 05/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3500 RANCH ROAD 620 S STE A100
-----------------------------------------------------
City | BEE CAVE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78738-7154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-502-5161
-----------------------------------------------------
Fax | 512-502-5227
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 311 MONTALCINO BLVD
-----------------------------------------------------
City | LAKEWAY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78734-5089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-504-2962
-----------------------------------------------------
Fax | 512-645-0328
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 47301
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------