Provider Demographics
NPI:1538458237
Name:MOUANOUTOUA, PAULA Y
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:Y
Last Name:MOUANOUTOUA
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 1:1544 N. CHERRYLANE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619
Mailing Address - Country:US
Mailing Address - Phone:559-355-0473
Mailing Address - Fax:559-229-8093
Practice Address - Street 1:1544 N. CHERRYLANE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93619
Practice Address - Country:US
Practice Address - Phone:559-355-0473
Practice Address - Fax:559-229-8093
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51215183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist