Provider Demographics
NPI:1639452717
Name:OKONKWO, PETER CHIKA
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:CHIKA
Last Name:OKONKWO
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 1:102 E VILLA CAPRI CIR APT E
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-7837
Mailing Address - Country:US
Mailing Address - Phone:954-655-9541
Mailing Address - Fax:
Practice Address - Street 1:100 E INTERNATIONAL SPEEDWAY BLVD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-2374
Practice Address - Country:US
Practice Address - Phone:386-738-4371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-24
Last Update Date:2011-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS39934183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist