Provider Demographics
NPI:1205591047
Name:SHINWIN AMBEBI NUMFOR, UNKNOWN
Entity type:Individual
Prefix:
First Name:UNKNOWN
Middle Name:
Last Name:SHINWIN AMBEBI NUMFOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:SHINWIN
Other - Middle Name:AMBEBI
Other - Last Name:NUMFOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4109 S STAPLES ST
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-5500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4109 S STAPLES ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-5500
Practice Address - Country:US
Practice Address - Phone:361-994-9015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-06
Last Update Date:2021-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69498183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist