Provider Demographics
NPI:1104704071
Name:OKBAMICHAEL, TES
Entity type:Individual
Prefix:
First Name:TES
Middle Name:
Last Name:OKBAMICHAEL
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 1:7875 TYRELL PEAKS ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-6561
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2610 S JONES BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-5663
Practice Address - Country:US
Practice Address - Phone:702-619-3575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-26
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV24210183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist