Provider Demographics
NPI:1316415243
Name:MAKETIWA, MONALISA FAINA (RPH)
Entity Type:Individual
Prefix:
First Name:MONALISA
Middle Name:FAINA
Last Name:MAKETIWA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:MONALISA
Other - Middle Name:FAINA
Other - Last Name:MUZANENHAMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:629 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-3039
Mailing Address - Country:US
Mailing Address - Phone:270-825-1541
Mailing Address - Fax:
Practice Address - Street 1:679 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-3039
Practice Address - Country:US
Practice Address - Phone:270-825-1541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2018-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26027881A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist