Provider Demographics
NPI:1376085274
Name:OUABO, BRIGITTE
Entity Type:Individual
Prefix:
First Name:BRIGITTE
Middle Name:
Last Name:OUABO
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 1:1525 FRANCISCO BLVD E
Mailing Address - Street 2:2
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-5539
Mailing Address - Country:US
Mailing Address - Phone:415-455-9042
Mailing Address - Fax:415-455-9318
Practice Address - Street 1:1525 FRANCISCO BLVD E
Practice Address - Street 2:2
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-5539
Practice Address - Country:US
Practice Address - Phone:415-455-9042
Practice Address - Fax:415-455-9318
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74974183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist