Provider Demographics
NPI:1710423025
Name:TABANG, TOLEFAC AKEM
Entity Type:Individual
Prefix:
First Name:TOLEFAC
Middle Name:AKEM
Last Name:TABANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1/2 MILE S OF MP 394.3
Mailing Address - Street 2:
Mailing Address - City:KAYENTA
Mailing Address - State:AZ
Mailing Address - Zip Code:86033
Mailing Address - Country:US
Mailing Address - Phone:240-899-8677
Mailing Address - Fax:
Practice Address - Street 1:1/2 MILE S OF MP 394.3
Practice Address - Street 2:KAYENTA HEALTH CENTER
Practice Address - City:KAYENTA
Practice Address - State:AZ
Practice Address - Zip Code:86033
Practice Address - Country:US
Practice Address - Phone:240-899-8677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02022153861835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care