Provider Demographics
NPI:1508318122
Name:EKWONNAH, CHISOM
Entity Type:Individual
Prefix:
First Name:CHISOM
Middle Name:
Last Name:EKWONNAH
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 1:5850 GULFTON ST
Mailing Address - Street 2:1862
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77081-2597
Mailing Address - Country:US
Mailing Address - Phone:832-466-8406
Mailing Address - Fax:
Practice Address - Street 1:4517 N MIDLAND DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79707-3325
Practice Address - Country:US
Practice Address - Phone:432-697-2299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX56264183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist