Provider Demographics
NPI:1043430614
Name:EVBUOMWAN, FAUSTINA NIYEMAMWEN (BSC PHARM)
Entity Type:Individual
Prefix:MRS
First Name:FAUSTINA
Middle Name:NIYEMAMWEN
Last Name:EVBUOMWAN
Suffix:
Gender:F
Credentials:BSC PHARM
Other - Prefix:MISS
Other - First Name:FAUSTINA
Other - Middle Name:NIYEMAMWEN
Other - Last Name:OYEGUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1801
Mailing Address - Street 2:
Mailing Address - City:FORT DEFIANCE
Mailing Address - State:AZ
Mailing Address - Zip Code:86504-1801
Mailing Address - Country:US
Mailing Address - Phone:928-729-2938
Mailing Address - Fax:928-729-8348
Practice Address - Street 1:PHARMACY DEPARTMENT, FDIH
Practice Address - Street 2:JUNCTION OF RT12 & RT 7
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:928-729-8328
Practice Address - Fax:928-729-8348
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14355183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
313404259-1OtherUNITED HEALTHCARE INSURAN