Provider Demographics
NPI:1982460523
Name:EZUMBA, OGOCHUKWU N
Entity Type:Individual
Prefix:MR
First Name:OGOCHUKWU
Middle Name:N
Last Name:EZUMBA
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 1:2326 E MENLO BLVD
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-2608
Mailing Address - Country:US
Mailing Address - Phone:141-470-8391
Mailing Address - Fax:
Practice Address - Street 1:5715 W APPLETON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-2250
Practice Address - Country:US
Practice Address - Phone:414-988-2188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302048478183500000X
WI21263-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist