Provider Demographics
NPI:1427360403
Name:EZIRIM, IHEANACHO AHAMEFULA
Entity Type:Individual
Prefix:MR
First Name:IHEANACHO
Middle Name:AHAMEFULA
Last Name:EZIRIM
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 1:311 MONTALCINO BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-5089
Mailing Address - Country:US
Mailing Address - Phone:409-504-2962
Mailing Address - Fax:512-645-0328
Practice Address - Street 1:3500 RANCH ROAD 620 S STE A100
Practice Address - Street 2:
Practice Address - City:BEE CAVE
Practice Address - State:TX
Practice Address - Zip Code:78738-7154
Practice Address - Country:US
Practice Address - Phone:512-502-5161
Practice Address - Fax:512-502-5227
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX47301183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist