Provider Demographics
NPI:1154661114
Name:OTEGBULU, KELECHI CHARLES (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELECHI
Middle Name:CHARLES
Last Name:OTEGBULU
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 1:6795 CALDER AVE
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-6007
Mailing Address - Country:US
Mailing Address - Phone:409-860-3909
Mailing Address - Fax:
Practice Address - Street 1:6795 CALDER AVE
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-6007
Practice Address - Country:US
Practice Address - Phone:409-860-3909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-27
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX52262183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist