Provider Demographics
NPI:1760243190
Name:MOUNGANG, BECKER
Entity Type:Individual
Prefix:
First Name:BECKER
Middle Name:
Last Name:MOUNGANG
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 1:235 W GROVE ST APT A5
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1653
Mailing Address - Country:US
Mailing Address - Phone:626-354-2451
Mailing Address - Fax:
Practice Address - Street 1:2120 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-1856
Practice Address - Country:US
Practice Address - Phone:626-863-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89184183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist