Provider Demographics
NPI:1912289067
Name:AGENE, FUNMILAYO A
Entity Type:Individual
Prefix:MRS
First Name:FUNMILAYO
Middle Name:A
Last Name:AGENE
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 1:801 INDEPENDENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6003
Mailing Address - Country:US
Mailing Address - Phone:757-519-9877
Mailing Address - Fax:757-519-9894
Practice Address - Street 1:2348 FENWICK WAY
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23453-2872
Practice Address - Country:US
Practice Address - Phone:757-450-2301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202207758183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist