Healthcare Provider Details

I. General information

NPI: 1609464247
Provider Name (Legal Business Name): SMART MEBUGE PHARM.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2021
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 MONTANA AVE
EL PASO TX
79903-4909
US

IV. Provider business mailing address

7227 N MESA ST APT 807
EL PASO TX
79912-3635
US

V. Phone/Fax

Practice location:
  • Phone: 915-779-8825
  • Fax:
Mailing address:
  • Phone: 347-393-2868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number62359
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: