Provider Demographics
NPI:1184264384
Name:ETAKIBUEBU, JOHN (PHARMD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:ETAKIBUEBU
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 HWY 79 S
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75652
Mailing Address - Country:US
Mailing Address - Phone:903-657-8596
Mailing Address - Fax:
Practice Address - Street 1:2415 HWY 79 S
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75652
Practice Address - Country:US
Practice Address - Phone:903-657-8596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX542481835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist