Provider Demographics
NPI:1285245993
Name:EGWIM, AUGUSTINA O (ETC)
Entity type:Individual
Prefix:DR
First Name:AUGUSTINA
Middle Name:O
Last Name:EGWIM
Suffix:
Gender:F
Credentials:ETC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 MARYLAND AVE E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-2850
Mailing Address - Country:US
Mailing Address - Phone:651-774-3011
Mailing Address - Fax:
Practice Address - Street 1:1401 MARYLAND AVE E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-2850
Practice Address - Country:US
Practice Address - Phone:651-774-3011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN123638183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN123638OtherPHARMACIST LICENSE