Provider Demographics
NPI:1700525417
Name:STEPHEN AGBOIRE, LELI OMECHAM (RPH)
Entity Type:Individual
Prefix:
First Name:LELI
Middle Name:OMECHAM
Last Name:STEPHEN AGBOIRE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2408 ROSHARON DR
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-2450
Mailing Address - Country:US
Mailing Address - Phone:469-605-8251
Mailing Address - Fax:
Practice Address - Street 1:WALGREENS
Practice Address - Street 2:4415 NORTH STATE LINE AVENUE
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503
Practice Address - Country:US
Practice Address - Phone:903-792-8918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64715183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX64715OtherTEXAS STATE BOARD OF PHARMACY