Provider Demographics
NPI:1619632841
Name:EGBUCHUNAM, IKE C
Entity Type:Individual
Prefix:
First Name:IKE
Middle Name:C
Last Name:EGBUCHUNAM
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 1:14211 COIT RD STE 1
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-2862
Mailing Address - Country:US
Mailing Address - Phone:972-807-2527
Mailing Address - Fax:
Practice Address - Street 1:14211 COIT RD STE 1
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-2862
Practice Address - Country:US
Practice Address - Phone:972-807-2527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-02
Last Update Date:2023-01-11
Deactivation Date:2022-03-23
Deactivation Code:
Reactivation Date:2023-01-11
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy