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General NPI Number Information
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NPI Number | 1992213672
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Entity Type | Individual
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Provider Name | DR. LADANA SHAREICE MBOUP
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Gender | Female
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Dates
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Enumeration Date | 01/17/2018
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Last Update Date | 01/17/2018
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Provider Practice Location Address
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Address Line | 250 PALM COAST PKWY NE UNIT 100
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City | PALM COAST
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State | FL
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Zip | 32137-8224
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Country | US
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Telephone | 386-597-4776
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Fax | 386-597-4781
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Provider Business Mailing Address
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Address Line | 250 PALM COAST PKWY NE UNIT 100
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City | PALM COAST
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State | FL
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Zip | 32137-8224
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Country | US
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Telephone | 386-597-4776
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Fax | 386-597-4781
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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 | PS56224
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License Number State | FL
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