Healthcare Provider Details

I. General information

NPI: 1740971456
Provider Name (Legal Business Name): WILLIET NGWEBENG MUBAH RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 EXPRESSWAY CT
VIRGINIA BEACH VA
23462-6526
US

IV. Provider business mailing address

119 BIRDIE DR
SUFFOLK VA
23434-9283
US

V. Phone/Fax

Practice location:
  • Phone: 757-499-9637
  • Fax:
Mailing address:
  • Phone: 757-768-1010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number0202221048
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: