Provider Demographics
NPI:1427738616
Name:MBONU, PRINCE CHARLES CHIBUIKE
Entity type:Individual
Prefix:
First Name:PRINCE CHARLES
Middle Name:CHIBUIKE
Last Name:MBONU
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 1:22000 CABIN BRANCH AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20871-3433
Mailing Address - Country:US
Mailing Address - Phone:240-889-7945
Mailing Address - Fax:
Practice Address - Street 1:6851 TEMIE LEE PKWY
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2087
Practice Address - Country:US
Practice Address - Phone:804-639-0439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202221240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist