Provider Demographics
NPI:1063136976
Name:OBEGOLU, JACHIKEH MATTHEW
Entity type:Individual
Prefix:
First Name:JACHIKEH
Middle Name:MATTHEW
Last Name:OBEGOLU
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 1:833 SW WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-5712
Mailing Address - Country:US
Mailing Address - Phone:817-447-4172
Mailing Address - Fax:817-447-4177
Practice Address - Street 1:833 SW WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-5712
Practice Address - Country:US
Practice Address - Phone:817-447-4172
Practice Address - Fax:817-447-4177
Is Sole Proprietor?:No
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35382183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist