Provider Demographics
NPI:1639430200
Name:MBOUYO, SANDRINE CLAIRE (RPH)
Entity Type:Individual
Prefix:
First Name:SANDRINE
Middle Name:CLAIRE
Last Name:MBOUYO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-3616
Mailing Address - Country:US
Mailing Address - Phone:862-236-1348
Mailing Address - Fax:862-236-1349
Practice Address - Street 1:810 SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-3616
Practice Address - Country:US
Practice Address - Phone:862-236-1348
Practice Address - Fax:862-236-1349
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
NJ28RI04159700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No374U00000XNursing Service Related ProvidersHome Health Aide