Provider Demographics
NPI:1508524679
Name:MBANGU KOT MBAU, RICA (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:RICA
Middle Name:
Last Name:MBANGU KOT MBAU
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20526 E KENYON PL
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80013-6608
Mailing Address - Country:US
Mailing Address - Phone:303-638-8121
Mailing Address - Fax:
Practice Address - Street 1:20526 E KENYON PL
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80013-6608
Practice Address - Country:US
Practice Address - Phone:303-638-8121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23816183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist