Provider Demographics
NPI:1639445737
Name:MALAVE, WANDA IVELISSE
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:IVELISSE
Last Name:MALAVE
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 1:6045 BARONSCOURT WAY
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-6091
Mailing Address - Country:US
Mailing Address - Phone:614-389-2873
Mailing Address - Fax:614-389-2873
Practice Address - Street 1:1444 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:GRANDVIEW HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:43212-2400
Practice Address - Country:US
Practice Address - Phone:614-486-3308
Practice Address - Fax:614-486-3656
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03230733183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist