Provider Demographics
NPI:1407682784
Name:GRACE PHARMACY
Entity type:Organization
Organization Name:GRACE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:(PIC) OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHIGOZIE
Authorized Official - Middle Name:GILBERT
Authorized Official - Last Name:OGUH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:915-593-0603
Mailing Address - Street 1:11140 LA QUINTA PL #101A
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936
Mailing Address - Country:US
Mailing Address - Phone:915-593-0603
Mailing Address - Fax:915-593-3378
Practice Address - Street 1:11140 LA QUINTA PL #101A
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936
Practice Address - Country:US
Practice Address - Phone:915-593-0603
Practice Address - Fax:915-593-3378
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149185Medicaid