Provider Demographics
NPI:1174823611
Name:NANAKUMO, VENAN EBIMOBOWEI (MPHARM)
Entity Type:Individual
Prefix:
First Name:VENAN
Middle Name:EBIMOBOWEI
Last Name:NANAKUMO
Suffix:
Gender:M
Credentials:MPHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 W WATERS AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-2802
Mailing Address - Country:US
Mailing Address - Phone:813-931-3700
Mailing Address - Fax:
Practice Address - Street 1:1412 W WATERS AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-2802
Practice Address - Country:US
Practice Address - Phone:813-931-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH323641835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy