Provider Demographics
NPI:1093431843
Name:CHAM, ABUOLA OMOT
Entity Type:Individual
Prefix:DR
First Name:ABUOLA
Middle Name:OMOT
Last Name:CHAM
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 1:3601 JACKSBORO HWY
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76302-1638
Mailing Address - Country:US
Mailing Address - Phone:940-766-0174
Mailing Address - Fax:940-766-4174
Practice Address - Street 1:3601 JACKSBORO HWY
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76302-1638
Practice Address - Country:US
Practice Address - Phone:640-766-0174
Practice Address - Fax:940-766-4174
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX54458183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4507565Medicaid