Provider Demographics
NPI:1598025454
Name:TAKU, EBOT NDEMAZE (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:EBOT
Middle Name:NDEMAZE
Last Name:TAKU
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3506 SKYLINE BLVD APT 22
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-1433
Mailing Address - Country:US
Mailing Address - Phone:240-704-4117
Mailing Address - Fax:
Practice Address - Street 1:4415 N STATELINE AVE
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3138
Practice Address - Country:US
Practice Address - Phone:240-704-4117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-24
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
TX66729183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No374U00000XNursing Service Related ProvidersHome Health Aide