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General NPI Number Information
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NPI Number | 1598025454
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Entity Type | Individual
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Provider Name | EBOT NDEMAZE TAKU PHARMACIST
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Gender | Female
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Dates
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Enumeration Date | 05/24/2012
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Last Update Date | 06/07/2022
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Provider Practice Location Address
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Address Line | 4415 N STATELINE AVE
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City | TEXARKANA
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State | TX
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Zip | 75503-3138
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Country | US
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Telephone | 240-704-4117
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Fax |
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Provider Business Mailing Address
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Address Line | 3506 SKYLINE BLVD APT 22
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City | TEXARKANA
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State | TX
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Zip | 75503-1433
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Country | US
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Telephone | 240-704-4117
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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 | 374U00000X
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Taxonomy Name | Home Health Aide
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 66729
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License Number State | TX
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