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General NPI Number Information
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NPI Number | 1912289067
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Entity Type | Individual
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Provider Name | MRS. FUNMILAYO A AGENE
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Gender | Female
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Dates
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Enumeration Date | 09/14/2011
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Last Update Date | 09/27/2021
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Provider Practice Location Address
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Address Line | 2348 FENWICK WAY
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City | VIRGINIA BEACH
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State | VA
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Zip | 23453-2872
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Country | US
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Telephone | 757-450-2301
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Fax |
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Provider Business Mailing Address
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Address Line | 801 INDEPENDENCE BLVD
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City | VIRGINIA BEACH
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State | VA
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Zip | 23455-6003
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Country | US
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Telephone | 757-519-9877
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Fax | 757-519-9894
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 0202207758
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License Number State | VA
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