Basic Information
Provider Information | |||||||||
NPI: | 1184738809 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOMON-UGWU | ||||||||
FirstName: | RENEE | ||||||||
MiddleName: | MASHELL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARMD, BCNSP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MOMON | ||||||||
OtherFirstName: | RENEE | ||||||||
OtherMiddleName: | MASHELL | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PHARMD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 19051 NW 78TH PL | ||||||||
Address2: |   | ||||||||
City: | HIALEAH | ||||||||
State: | FL | ||||||||
PostalCode: | 330152758 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3058298219 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1201 NW 16TH ST | ||||||||
Address2: |   | ||||||||
City: | MIAMI | ||||||||
State: | FL | ||||||||
PostalCode: | 331251624 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3055757000 | ||||||||
FaxNumber: | 3055753386 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/19/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 16149 | GA | X |   | Pharmacy Service Providers | Pharmacist |   | 1835N1003X | PS25295 | FL | X |   | Pharmacy Service Providers | Pharmacist | Nutrition Support |
No ID Information.