1700525417 NPI number — LELI OMECHAM STEPHEN AGBOIRE RPH

Table of content: LELI OMECHAM STEPHEN AGBOIRE RPH (NPI 1700525417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700525417 NPI number — LELI OMECHAM STEPHEN AGBOIRE RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STEPHEN AGBOIRE
Provider First Name:
LELI
Provider Middle Name:
OMECHAM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RPH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700525417
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2408 ROSHARON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORNEY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75126-2450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-605-8251
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
WALGREENS
Provider Second Line Business Practice Location Address:
4415 NORTH STATE LINE AVENUE
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-792-8918
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/01/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  64715 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 64715 . This is a "TEXAS STATE BOARD OF PHARMACY" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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