Provider Demographics
NPI:1407415144
Name:AGWUMEZIE, JULITA CHINYERE
Entity Type:Individual
Prefix:
First Name:JULITA
Middle Name:CHINYERE
Last Name:AGWUMEZIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1590 SYCAMORE AVENUE
Mailing Address - Street 2:
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547
Mailing Address - Country:US
Mailing Address - Phone:510-415-1857
Mailing Address - Fax:
Practice Address - Street 1:1590 SYCAMORE AVENUE
Practice Address - Street 2:
Practice Address - City:HERCULES
Practice Address - State:CA
Practice Address - Zip Code:94547
Practice Address - Country:US
Practice Address - Phone:510-415-1857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57751183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist