Provider Demographics
NPI:1811361462
Name:GINIGEME, AZUKA
Entity Type:Individual
Prefix:
First Name:AZUKA
Middle Name:
Last Name:GINIGEME
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 1:520 DOWLEN RD
Mailing Address - Street 2:APT 93
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-6080
Mailing Address - Country:US
Mailing Address - Phone:469-667-6932
Mailing Address - Fax:
Practice Address - Street 1:3605 COLLEGE STREET
Practice Address - Street 2:WALGREENS PHARMACY
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701
Practice Address - Country:US
Practice Address - Phone:409-832-7374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX55878183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist