Provider Demographics
NPI:1417568254
Name:EKPO, EKWERE JOHNSON
Entity Type:Individual
Prefix:
First Name:EKWERE
Middle Name:JOHNSON
Last Name:EKPO
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 1:6462 RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-4160
Mailing Address - Country:US
Mailing Address - Phone:770-519-3604
Mailing Address - Fax:
Practice Address - Street 1:1800 BROWN BLVD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76006-4602
Practice Address - Country:US
Practice Address - Phone:770-519-3604
Practice Address - Fax:817-459-2880
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX53320183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist