Provider Demographics
NPI:1821783408
Name:OMBASA, JUDDY
Entity Type:Individual
Prefix:
First Name:JUDDY
Middle Name:
Last Name:OMBASA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3057 HERITAGE CIR
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606-3314
Mailing Address - Country:US
Mailing Address - Phone:682-313-7290
Mailing Address - Fax:
Practice Address - Street 1:965 N JUDGE ELY BLVD
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-4626
Practice Address - Country:US
Practice Address - Phone:325-677-0616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69656183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist