Provider Demographics
NPI:1619580339
Name:OGBUEZE, LILIAN NDIDI
Entity Type:Individual
Prefix:
First Name:LILIAN
Middle Name:NDIDI
Last Name:OGBUEZE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11103 W MILITARY DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-3903
Mailing Address - Country:US
Mailing Address - Phone:210-679-5267
Mailing Address - Fax:210-679-0460
Practice Address - Street 1:11103 W MILITARY DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-3903
Practice Address - Country:US
Practice Address - Phone:210-679-5267
Practice Address - Fax:210-679-0460
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX57253183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1851308803Medicaid