Provider Demographics
NPI:1780906131
Name:MATUNGULU, MUTOMBO JC (RPH)
Entity type:Individual
Prefix:MR
First Name:MUTOMBO
Middle Name:JC
Last Name:MATUNGULU
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 FRANK SOTTILE BLVD
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-1550
Mailing Address - Country:US
Mailing Address - Phone:845-366-7460
Mailing Address - Fax:
Practice Address - Street 1:601 FRANK SOTTILE BLVD
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-1550
Practice Address - Country:US
Practice Address - Phone:845-366-7460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051250183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist