Provider Demographics
NPI:1619632585
Name:MBANU, CHIMEZIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:CHIMEZIE
Middle Name:
Last Name:MBANU
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12203 YEARLING PL
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-7658
Mailing Address - Country:US
Mailing Address - Phone:156-227-8442
Mailing Address - Fax:
Practice Address - Street 1:42155 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-8006
Practice Address - Country:US
Practice Address - Phone:760-345-3259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84710183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist