Provider Demographics
NPI:1487245940
Name:GURUNG, MAMITA
Entity type:Individual
Prefix:
First Name:MAMITA
Middle Name:
Last Name:GURUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2768 CRICKLEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-8286
Mailing Address - Country:US
Mailing Address - Phone:571-438-3691
Mailing Address - Fax:
Practice Address - Street 1:1341 LONG ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-4935
Practice Address - Country:US
Practice Address - Phone:434-296-0156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202210418183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist