Provider Demographics
NPI:1376863183
Name:ETEBOM, FELIX F (BS BSPHARM)
Entity Type:Individual
Prefix:MR
First Name:FELIX
Middle Name:F
Last Name:ETEBOM
Suffix:
Gender:M
Credentials:BS BSPHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13202 STEEPLECHASE DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-4542
Mailing Address - Country:US
Mailing Address - Phone:301-352-2514
Mailing Address - Fax:301-805-0664
Practice Address - Street 1:13202 STEEPLECHASE DR
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20715-4542
Practice Address - Country:US
Practice Address - Phone:301-352-2514
Practice Address - Fax:301-805-0664
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD137801835N1003X, 1835P0018X, 1835G0303X, 1835P1200X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835N1003XPharmacy Service ProvidersPharmacistNutrition Support
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No1835G0303XPharmacy Service ProvidersPharmacistGeriatric
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CPN # 202-0014OtherAPHA-NATIONAL CERTIFICATE PROGRAM FOR PHARMACIST COMPREHENSIVE IMMUNIZATION .
PPSP LLCOtherPHARMACY & PHARMACEUTICAL SERVICES PROVIDER (PPSP)
URLOtherHTTP://WWW.PHARMACYPHARMACEUTICALSERVICES.COM
PPSP LLCOtherPHARMACY & PHARMACEUTICAL SERVICES PROVIDER (PPSP)