Provider Demographics
NPI:1720604523
Name:AGANZE, ALICE NSHAMAMBA
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:NSHAMAMBA
Last Name:AGANZE
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 1:5715 TOWN CENTER DR APT 10
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-4425
Mailing Address - Country:US
Mailing Address - Phone:773-744-2389
Mailing Address - Fax:
Practice Address - Street 1:1010 E IRELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2665
Practice Address - Country:US
Practice Address - Phone:574-299-0154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26026996A183500000X
MI5302046775183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist