Provider Demographics
NPI:1255679585
Name:AGWAMBA, ISRAEL C (RPH)
Entity Type:Individual
Prefix:MR
First Name:ISRAEL
Middle Name:C
Last Name:AGWAMBA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11219 SNOWDEN POND RD
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-3066
Mailing Address - Country:US
Mailing Address - Phone:301-254-4900
Mailing Address - Fax:
Practice Address - Street 1:3180 BLADENSBURG RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018
Practice Address - Country:US
Practice Address - Phone:202-269-0000
Practice Address - Fax:202-269-0100
Is Sole Proprietor?:No
Enumeration Date:2013-01-22
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPH3254183500000X
MD13868183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist