Provider Demographics
NPI:1588181846
Name:EGHAREVBA, ESEOSA (PHARM D)
Entity Type:Individual
Prefix:
First Name:ESEOSA
Middle Name:
Last Name:EGHAREVBA
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2602 W RICHEY AVE APT 1705
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:NM
Mailing Address - Zip Code:88210-9673
Mailing Address - Country:US
Mailing Address - Phone:575-513-0650
Mailing Address - Fax:
Practice Address - Street 1:604 N 26TH ST
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:NM
Practice Address - Zip Code:88210-3723
Practice Address - Country:US
Practice Address - Phone:575-746-6137
Practice Address - Fax:575-746-6767
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00008666183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist