Provider Demographics
NPI:1306431812
Name:KIGOTHO, WALLACE
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:
Last Name:KIGOTHO
Suffix:
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 1:2202 MARTIN LUTHER KING JR AVE SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-5725
Mailing Address - Country:US
Mailing Address - Phone:202-678-6010
Mailing Address - Fax:
Practice Address - Street 1:2202 MARTIN LUTHER KING JR AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-5725
Practice Address - Country:US
Practice Address - Phone:202-678-6010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPH100000679183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist