Provider Demographics
NPI:1518578228
Name:MWENDWA, JACQUILINE
Entity Type:Individual
Prefix:
First Name:JACQUILINE
Middle Name:
Last Name:MWENDWA
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 1:3228 WRIGHTSBORO RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-2937
Mailing Address - Country:US
Mailing Address - Phone:706-733-3715
Mailing Address - Fax:706-733-5365
Practice Address - Street 1:3228 WRIGHTSBORO RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-2937
Practice Address - Country:US
Practice Address - Phone:706-733-3715
Practice Address - Fax:706-733-5365
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH028351183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist