Provider Demographics
NPI:1922818194
Name:EBANG, VENTIANE GRACE (PHARMD)
Entity type:Individual
Prefix:
First Name:VENTIANE
Middle Name:GRACE
Last Name:EBANG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9109 FRIAR RD
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-6802
Mailing Address - Country:US
Mailing Address - Phone:202-617-8792
Mailing Address - Fax:
Practice Address - Street 1:13926 ROUTE 29
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20120-2415
Practice Address - Country:US
Practice Address - Phone:703-259-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-10
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202222561183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist