Provider Demographics
NPI:1790310019
Name:EJIMADU, ANTHONY E
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:E
Last Name:EJIMADU
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 1:5806 SAWMILL BEND LN
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-1261
Mailing Address - Country:US
Mailing Address - Phone:713-256-0180
Mailing Address - Fax:
Practice Address - Street 1:9275 RICHMOND AVE
Practice Address - Street 2:STE 114
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77063
Practice Address - Country:US
Practice Address - Phone:713-256-0180
Practice Address - Fax:832-582-6270
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-06
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31691183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150311Medicaid