Provider Demographics
NPI:1861006736
Name:NWOLISA, IFEYINWA B
Entity Type:Individual
Prefix:
First Name:IFEYINWA
Middle Name:B
Last Name:NWOLISA
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 1:4104 CISCO VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-3939
Mailing Address - Country:US
Mailing Address - Phone:512-552-6340
Mailing Address - Fax:
Practice Address - Street 1:1801 N OREGON ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-3524
Practice Address - Country:US
Practice Address - Phone:915-521-6110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66930183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist