Provider Demographics
NPI:1003054057
Name:MONGOH, NGALE NDIVA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:NGALE
Middle Name:NDIVA
Last Name:MONGOH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 MALLETTE DR
Mailing Address - Street 2:# 525
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-3382
Mailing Address - Country:US
Mailing Address - Phone:361-572-0777
Mailing Address - Fax:
Practice Address - Street 1:325 S. HWY. 35 BY PASS
Practice Address - Street 2:
Practice Address - City:PORT LAVACA
Practice Address - State:TX
Practice Address - Zip Code:77979
Practice Address - Country:US
Practice Address - Phone:361-552-7486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX46316183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist