Active NPI
Ikenna Modebelu
- Pharmacist
- Fort Worth, TX
National Provider Identifier
1104420397
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- 57121
- Practice address
- 5201 Golden Triangle Blvd
Fort Worth, TX 76244-4468 - Phone
- (817) 741-4330
- NPI assigned
- Nov 28, 2020
- Last updated
- Nov 28, 2020
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | PH238079 | MA | |
| Pharmacist | 183500000X | 57121 | TX | Primary |
Addresses
Primary practice location
5201 Golden Triangle Blvd
Fort Worth, TX 76244-4468
Mailing address
9617 Wexley Way
Fort Worth, TX 76131-1486
Phone (781) 413-6006
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PH238079 | MA | MD | Pharmacist |
| 57121 | TX | MD | Pharmacist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| CVS Pharmacy, Inc | Past | Accepting new patients | |
| CVS Pharmacy Inc | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1606521600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1606521600000",
"number": "1104420397",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "9617 WEXLEY WAY",
"city": "FORT WORTH",
"state": "TX",
"postal_code": "761311486",
"telephone_number": "781-413-6006"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "5201 GOLDEN TRIANGLE BLVD",
"city": "FORT WORTH",
"state": "TX",
"postal_code": "762444468",
"telephone_number": "817-741-4330"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MODEBELU",
"first_name": "IKENNA",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2020-11-28",
"last_updated": "2020-11-28",
"certification_date": "2020-11-28",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "MA",
"license": "PH238079",
"primary": false
},
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "TX",
"license": "57121",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fort Worth, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 28, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.