Provider Demographics
NPI:1669089793
Name:NWACHUKWU, NWAMAKA
Entity type:Individual
Prefix:
First Name:NWAMAKA
Middle Name:
Last Name:NWACHUKWU
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 1:7220 103RD CT N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55445-2476
Mailing Address - Country:US
Mailing Address - Phone:817-714-1975
Mailing Address - Fax:
Practice Address - Street 1:4000 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:COLUMBIA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55421-2968
Practice Address - Country:US
Practice Address - Phone:763-782-8149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN122523183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN122523OtherMN BOARD OF PHARMACY