Provider Demographics
NPI:1669133682
Name:GUANGULE, AGENAGNE MOLLA
Entity type:Individual
Prefix:
First Name:AGENAGNE
Middle Name:MOLLA
Last Name:GUANGULE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 CENTER ST APT 204
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-5010
Mailing Address - Country:US
Mailing Address - Phone:571-299-0725
Mailing Address - Fax:
Practice Address - Street 1:2460 PRINCE WILLIAM PKWY
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-4148
Practice Address - Country:US
Practice Address - Phone:703-490-4415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-02
Last Update Date:2022-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202219321183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist