Healthcare Provider Details

I. General information

NPI: 1881096956
Provider Name (Legal Business Name): CLARENCE DOBGIMA GWANBOBMUGA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2014
Last Update Date: 09/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3216 E 7TH ST
LUBBOCK TX
79403-5606
US

IV. Provider business mailing address

3216 E 7TH ST
LUBBOCK TX
79403-5606
US

V. Phone/Fax

Practice location:
  • Phone: 404-514-5633
  • Fax:
Mailing address:
  • Phone: 404-514-5633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number53835
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: