Provider Demographics
NPI:1891147864
Name:NGAGOM PIEWE, FALLONE SIME NANA
Entity Type:Individual
Prefix:
First Name:FALLONE
Middle Name:SIME NANA
Last Name:NGAGOM PIEWE
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 1:5203 WOODFIELD DR
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-4126
Mailing Address - Country:US
Mailing Address - Phone:202-602-8266
Mailing Address - Fax:
Practice Address - Street 1:10 CROOKED RUN PLZ
Practice Address - Street 2:
Practice Address - City:FRONT ROYAL
Practice Address - State:VA
Practice Address - Zip Code:22630-7004
Practice Address - Country:US
Practice Address - Phone:540-631-3291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-01
Last Update Date:2024-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202221851183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty