Healthcare Provider Details

I. General information

NPI: 1649892811
Provider Name (Legal Business Name): MIRABEL EFUNDEM TANYI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2020
Last Update Date: 05/11/2020
Certification Date: 05/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9001 WOODY TER
CLINTON MD
20735-4255
US

IV. Provider business mailing address

9001 WOODY TER
CLINTON MD
20735-4255
US

V. Phone/Fax

Practice location:
  • Phone: 301-856-6501
  • Fax: 301-856-6507
Mailing address:
  • Phone: 301-856-6501
  • Fax: 301-856-6507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number27208
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: