Provider Demographics
NPI:1689141327
Name:ABONGWA, LILIANE (PHARMD, MBA)
Entity Type:Individual
Prefix:DR
First Name:LILIANE
Middle Name:
Last Name:ABONGWA
Suffix:
Gender:F
Credentials:PHARMD, MBA
Other - Prefix:DR
Other - First Name:LILIANE
Other - Middle Name:
Other - Last Name:MOFOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD, MBA
Mailing Address - Street 1:103 MEDICINE WAY RD
Mailing Address - Street 2:
Mailing Address - City:PERIDOT
Mailing Address - State:AZ
Mailing Address - Zip Code:85542
Mailing Address - Country:US
Mailing Address - Phone:928-475-1304
Mailing Address - Fax:
Practice Address - Street 1:103 MEDICINE WAY RD
Practice Address - Street 2:
Practice Address - City:PERIDOT
Practice Address - State:AZ
Practice Address - Zip Code:85542
Practice Address - Country:US
Practice Address - Phone:928-475-1304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1186681835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist