Provider Demographics
NPI:1285239954
Name:OMENUKOR, OBIKA
Entity type:Individual
Prefix:
First Name:OBIKA
Middle Name:
Last Name:OMENUKOR
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 1:1751 BISON MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:HEATH
Mailing Address - State:TX
Mailing Address - Zip Code:75032-5953
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:102 FM 1821
Practice Address - Street 2:
Practice Address - City:MINERAL WELLS
Practice Address - State:TX
Practice Address - Zip Code:76067-9114
Practice Address - Country:US
Practice Address - Phone:972-693-6498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65031183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist