=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699375238
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEX AGYEMANG
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2020
-----------------------------------------------------
Last Update Date | 11/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6301 NW QUANNAH PARKER TRL
-----------------------------------------------------
City | LAWTON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73505-1326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-510-0357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5201 CENTRAL FWY APT 1202
-----------------------------------------------------
City | WICHITA FALLS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76306-1388
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-449-9814
-----------------------------------------------------
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 | 65451
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 18687
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------