Provider Demographics
NPI:1174122576
Name:MBINGLO, PAUL SUIVEN (PHARM D)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:SUIVEN
Last Name:MBINGLO
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6237 94TH CT
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-8225
Mailing Address - Country:US
Mailing Address - Phone:773-216-2567
Mailing Address - Fax:
Practice Address - Street 1:6237 94TH CT
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-8225
Practice Address - Country:US
Practice Address - Phone:773-216-2567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18145183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist