Provider Demographics
NPI:1699375238
Name:AGYEMANG, ALEX
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:AGYEMANG
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 1:5201 CENTRAL FWY APT 1202
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76306-1388
Mailing Address - Country:US
Mailing Address - Phone:817-449-9814
Mailing Address - Fax:
Practice Address - Street 1:6301 NW QUANNAH PARKER TRL
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-1326
Practice Address - Country:US
Practice Address - Phone:580-510-0357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65451183500000X
OK18687183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist