Healthcare Provider Details

I. General information

NPI: 1043660038
Provider Name (Legal Business Name): WANYU LAMBIV RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 W MAIN ST
GAYLORD MI
49735-1859
US

IV. Provider business mailing address

2793 ATHENA DR
TROY MI
48083-2412
US

V. Phone/Fax

Practice location:
  • Phone: 989-732-5220
  • Fax: 989-731-4216
Mailing address:
  • Phone: 313-675-4724
  • Fax: 989-731-4216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302042545
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: