Provider Demographics
NPI:1790311231
Name:DURUGO, FESTUS
Entity Type:Individual
Prefix:DR
First Name:FESTUS
Middle Name:
Last Name:DURUGO
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 1:1004 HAMPTON DR
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-6505
Mailing Address - Country:US
Mailing Address - Phone:201-838-1029
Mailing Address - Fax:
Practice Address - Street 1:105 JORDAN PLAZA BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75704-2050
Practice Address - Country:US
Practice Address - Phone:903-533-8122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61368183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist