=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457036519
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NAIMAGBON ETANA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2023
-----------------------------------------------------
Last Update Date | 06/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 710 N MAIN ST
-----------------------------------------------------
City | SPRINGBORO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45066-8944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-748-1135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 MURIEL CT APT G
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45014-2969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-904-2167
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 03442979
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------