Healthcare Provider Details

I. General information

NPI: 1629491493
Provider Name (Legal Business Name): DUMAVO G ATSOU-DZINI PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2014
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 E KELLOGG DR
WICHITA KS
67218-1607
US

IV. Provider business mailing address

5500 E KELLOGG DR
WICHITA KS
67218-1607
US

V. Phone/Fax

Practice location:
  • Phone: 316-685-2221
  • Fax: 316-651-3615
Mailing address:
  • Phone: 316-685-2221
  • Fax: 316-651-3615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number1-15541
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: