Provider Demographics
NPI:1316281546
Name:MBAGWU, JOHN ROBERT (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:MBAGWU
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11000 OPTUM CIR
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-2503
Mailing Address - Country:US
Mailing Address - Phone:952-205-0323
Mailing Address - Fax:
Practice Address - Street 1:11000 OPTUM CIR
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-2503
Practice Address - Country:US
Practice Address - Phone:952-205-0323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-10
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN121083183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN121083OtherPHARMACIST LICENSE