Provider Demographics
NPI:1891115028
Name:CENTER FOR MEDICATION THERAPY MANAGEMENT & OUTCOMES RESEARCH
Entity Type:Organization
Organization Name:CENTER FOR MEDICATION THERAPY MANAGEMENT & OUTCOMES RESEARCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT PROFESSOR/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:OMBENGI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, MBA, MPH
Authorized Official - Phone:757-727-5455
Mailing Address - Street 1:19 INDIAN RD
Mailing Address - Street 2:PHARMACY ANNEX
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23669-0001
Mailing Address - Country:US
Mailing Address - Phone:757-727-5000
Mailing Address - Fax:757-727-5840
Practice Address - Street 1:19 INDIAN RD
Practice Address - Street 2:PHARMACY ANNEX
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23669-5420
Practice Address - Country:US
Practice Address - Phone:757-727-5000
Practice Address - Fax:757-727-5840
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAMPTON UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-28
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0201004569261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0201004569OtherSTATE BOARD PRACTICE LICENCE (PHARMACY)