Provider Demographics
NPI:1255969382
Name:NDUKWU, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:NDUKWU
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 1:10711 MASON DALE DR
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-6990
Mailing Address - Country:US
Mailing Address - Phone:610-462-3316
Mailing Address - Fax:
Practice Address - Street 1:13105 WORTHAM CENTER DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77065-5611
Practice Address - Country:US
Practice Address - Phone:713-442-4055
Practice Address - Fax:713-442-4058
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64564183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty