=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740971456
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIET NGWEBENG MUBAH RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2023
-----------------------------------------------------
Last Update Date | 05/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 247 EXPRESSWAY CT
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23462-6526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-499-9637
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 119 BIRDIE DR
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23434-9283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-768-1010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | 0202221048
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------