Provider Demographics
NPI:1518550235
Name:AIMUA, IMADE ETHEL
Entity Type:Individual
Prefix:
First Name:IMADE
Middle Name:ETHEL
Last Name:AIMUA
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:PO BOX 2071
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29071-2071
Mailing Address - Country:US
Mailing Address - Phone:141-335-5388
Mailing Address - Fax:
Practice Address - Street 1:2401 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4717
Practice Address - Country:US
Practice Address - Phone:803-796-8126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT033.0003378183500000X
MA23896183500000X
SC42809183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist