Provider Demographics
NPI:1710254198
Name:IBANGA, ANIETIE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:ANIETIE
Middle Name:
Last Name:IBANGA
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 1:2424 CALUMET ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-7506
Mailing Address - Country:US
Mailing Address - Phone:832-715-0311
Mailing Address - Fax:
Practice Address - Street 1:5205 DOWLING ST
Practice Address - Street 2:SUITE B
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-7411
Practice Address - Country:US
Practice Address - Phone:713-529-2728
Practice Address - Fax:713-529-2729
Is Sole Proprietor?:No
Enumeration Date:2011-11-29
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50322183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist