Provider Demographics
NPI:1104421718
Name:DIMPS, WUNGAVU TASHMON SR
Entity type:Individual
Prefix:
First Name:WUNGAVU
Middle Name:TASHMON
Last Name:DIMPS
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 W EMAUS AVE
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6847
Mailing Address - Country:US
Mailing Address - Phone:610-791-4404
Mailing Address - Fax:
Practice Address - Street 1:315 W EMAUS AVE
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6847
Practice Address - Country:US
Practice Address - Phone:610-791-4404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP041682L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP041682LMedicaid