Provider Demographics
NPI:1992213672
Name:MBOUP, LADANA SHAREICE
Entity Type:Individual
Prefix:DR
First Name:LADANA
Middle Name:SHAREICE
Last Name:MBOUP
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 1:250 PALM COAST PKWY NE UNIT 100
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8224
Mailing Address - Country:US
Mailing Address - Phone:386-597-4776
Mailing Address - Fax:386-597-4781
Practice Address - Street 1:250 PALM COAST PKWY NE UNIT 100
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8224
Practice Address - Country:US
Practice Address - Phone:386-597-4776
Practice Address - Fax:386-597-4781
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS56224183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist