Provider Demographics
NPI:1013571793
Name:MOMBEYARARA, TANYARADZWA
Entity Type:Individual
Prefix:
First Name:TANYARADZWA
Middle Name:
Last Name:MOMBEYARARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4904 BLUE RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-7501
Mailing Address - Country:US
Mailing Address - Phone:252-676-0062
Mailing Address - Fax:
Practice Address - Street 1:3121 SUNSET DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-6501
Practice Address - Country:US
Practice Address - Phone:325-942-6658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-27
Last Update Date:2019-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63596183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist