Provider Demographics
NPI:1376148346
Name:MAMBULA, MARTHA VICTORIA (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:VICTORIA
Last Name:MAMBULA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 MAIN ST UNIT 1210
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:RI
Mailing Address - Zip Code:02816-7887
Mailing Address - Country:US
Mailing Address - Phone:774-238-8094
Mailing Address - Fax:
Practice Address - Street 1:2400 WARWICK AVE
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02889-4263
Practice Address - Country:US
Practice Address - Phone:401-737-2305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH234595183500000X
RIRPH05393183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist