Provider Demographics
NPI:1538842984
Name:ENEWALLY, OBINWANNE IKENNA DARRELL
Entity type:Individual
Prefix:
First Name:OBINWANNE
Middle Name:IKENNA DARRELL
Last Name:ENEWALLY
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 1:12147 CEDARVALE ST
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-7263
Mailing Address - Country:US
Mailing Address - Phone:562-200-9740
Mailing Address - Fax:
Practice Address - Street 1:5837 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90001-1127
Practice Address - Country:US
Practice Address - Phone:323-233-2493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-11
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88140183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist