Provider Demographics
NPI:1922691872
Name:MSISHA, TAWENI
Entity Type:Individual
Prefix:
First Name:TAWENI
Middle Name:
Last Name:MSISHA
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 1:155 RICHWOOD CT
Mailing Address - Street 2:
Mailing Address - City:BELPRE
Mailing Address - State:OH
Mailing Address - Zip Code:45714-8239
Mailing Address - Country:US
Mailing Address - Phone:304-651-8470
Mailing Address - Fax:
Practice Address - Street 1:3400 DUDLEY AVE
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26104-1810
Practice Address - Country:US
Practice Address - Phone:304-428-0946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0011938183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5057523OtherNABP