Provider Demographics
NPI:1720456908
Name:EGENTI, EMMANUEL OKEZIE
Entity type:Individual
Prefix:MR
First Name:EMMANUEL
Middle Name:OKEZIE
Last Name:EGENTI
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:EMMANUEL
Other - Middle Name:OKEZIE
Other - Last Name:EGENTI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:350 WESTPARK WAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76040-3964
Mailing Address - Country:US
Mailing Address - Phone:817-545-6600
Mailing Address - Fax:817-545-6667
Practice Address - Street 1:350 WESTPARK WAY
Practice Address - Street 2:SUITE 300
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76040-3964
Practice Address - Country:US
Practice Address - Phone:817-545-6600
Practice Address - Fax:817-545-6667
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-04
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27886183500000X, 1835G0303X, 1835P0018X, 1835P1200X, 1835P1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
No1835G0303XPharmacy Service ProvidersPharmacistGeriatric
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
No1835P1300XPharmacy Service ProvidersPharmacistPsychiatric