Provider Demographics
NPI:1023618691
Name:AIGBIVBALU, DENEEN DOUGLAS (RPH)
Entity type:Individual
Prefix:MRS
First Name:DENEEN
Middle Name:DOUGLAS
Last Name:AIGBIVBALU
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:DENEEN
Other - Middle Name:
Other - Last Name:DOUGLAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3404 KINGSTON DR
Mailing Address - Street 2:
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77546-2222
Mailing Address - Country:US
Mailing Address - Phone:708-261-2039
Mailing Address - Fax:
Practice Address - Street 1:1710 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-5604
Practice Address - Country:US
Practice Address - Phone:281-482-5516
Practice Address - Fax:281-482-5629
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-31
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32619183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist