Provider Demographics
NPI:1386232551
Name:T NOUBOSSIE, LOIC
Entity Type:Individual
Prefix:
First Name:LOIC
Middle Name:
Last Name:T NOUBOSSIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 CRAIN HWY
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-4102
Mailing Address - Country:US
Mailing Address - Phone:301-952-7539
Mailing Address - Fax:
Practice Address - Street 1:5700 CRAIN HWY
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-4102
Practice Address - Country:US
Practice Address - Phone:301-952-7539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-04
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD27759183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist