Provider Demographics
NPI:1972129310
Name:METWELE, ROUBA
Entity Type:Individual
Prefix:
First Name:ROUBA
Middle Name:
Last Name:METWELE
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 1:21211 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2208
Mailing Address - Country:US
Mailing Address - Phone:586-776-7052
Mailing Address - Fax:
Practice Address - Street 1:21211 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2208
Practice Address - Country:US
Practice Address - Phone:586-776-7052
Practice Address - Fax:586-776-7048
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302412081183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist