Provider Demographics
NPI:1508628835
Name:EYONGEGBE, MARYMAGDALENE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARYMAGDALENE
Middle Name:
Last Name:EYONGEGBE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16029 CHARING CROSS DR
Mailing Address - Street 2:
Mailing Address - City:JUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:76247-1761
Mailing Address - Country:US
Mailing Address - Phone:832-453-3117
Mailing Address - Fax:
Practice Address - Street 1:810 W PIONEER PKWY
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-4708
Practice Address - Country:US
Practice Address - Phone:972-641-5744
Practice Address - Fax:972-641-0204
Is Sole Proprietor?:No
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68542183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist