Provider Demographics
NPI:1154733905
Name:DIVINE PROVIDENCE INC
Entity type:Organization
Organization Name:DIVINE PROVIDENCE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MODUPE
Authorized Official - Middle Name:
Authorized Official - Last Name:IROROBEJE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-778-3072
Mailing Address - Street 1:1729 E CHARLESTON BLVD STE F
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-1986
Mailing Address - Country:US
Mailing Address - Phone:702-778-3072
Mailing Address - Fax:702-778-0512
Practice Address - Street 1:1729 E CHARLESTON BLVD STE F
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-1986
Practice Address - Country:US
Practice Address - Phone:702-778-3072
Practice Address - Fax:702-778-0512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-28
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NVPH031963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1154733905Medicaid
2147176OtherPK