Provider Demographics
NPI:1326754979
Name:OBWOCHA, GEOFFREY
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:
Last Name:OBWOCHA
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 1:2021 ELMWOOD NORTH AVE APT 110
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-3825
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1230 E 8TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4638
Practice Address - Country:US
Practice Address - Phone:432-332-0116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX71854183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX37772549Medicaid