Provider Demographics
NPI:1093318982
Name:KWOKEM, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:KWOKEM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BUSINESS PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:KENEDY
Mailing Address - State:TX
Mailing Address - Zip Code:78119-2026
Mailing Address - Country:US
Mailing Address - Phone:830-583-9832
Mailing Address - Fax:
Practice Address - Street 1:200 BUSINESS PARK BLVD
Practice Address - Street 2:
Practice Address - City:KENEDY
Practice Address - State:TX
Practice Address - Zip Code:78119-2026
Practice Address - Country:US
Practice Address - Phone:830-583-9832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-21
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX57397183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist