Provider Demographics
NPI:1033843354
Name:IDAHOSA, OSAKPANMWAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:OSAKPANMWAN
Middle Name:
Last Name:IDAHOSA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 ARISTA BLVD APT 1023
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-1112
Mailing Address - Country:US
Mailing Address - Phone:817-877-6184
Mailing Address - Fax:
Practice Address - Street 1:4415 N STATELINE AVE
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3138
Practice Address - Country:US
Practice Address - Phone:903-792-8918
Practice Address - Fax:903-792-6198
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX58093183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist