Provider Demographics
NPI:1588259261
Name:AKINNIYI, VICTORINE EYONG
Entity type:Individual
Prefix:
First Name:VICTORINE
Middle Name:EYONG
Last Name:AKINNIYI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VICTORINE
Other - Middle Name:EYONG
Other - Last Name:AKINNIYI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7003 FLAMENCIA
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-5561
Mailing Address - Country:US
Mailing Address - Phone:832-754-8645
Mailing Address - Fax:
Practice Address - Street 1:2200 MATLOCK RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-3855
Practice Address - Country:US
Practice Address - Phone:817-453-0267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX44693183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
060340626OtherCVS PHARMACY
050340626OtherCVS PHARMACY