Provider Demographics
NPI:1386089498
Name:IKE, RAPHAEL
Entity type:Individual
Prefix:DR
First Name:RAPHAEL
Middle Name:
Last Name:IKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RAPHAEL
Other - Middle Name:
Other - Last Name:OGBUGBULU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7807 BOWENS CROSSING ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78250-2971
Mailing Address - Country:US
Mailing Address - Phone:210-374-0915
Mailing Address - Fax:
Practice Address - Street 1:4510 GARTH RD
Practice Address - Street 2:
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77521-2124
Practice Address - Country:US
Practice Address - Phone:281-691-6823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51297183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist