Provider Demographics
NPI:1699083766
Name:DOMINGUE, MONIQUE
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:DOMINGUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:
Other - Last Name:BARROIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1501 DELL RANGE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4853
Mailing Address - Country:US
Mailing Address - Phone:307-635-5854
Mailing Address - Fax:
Practice Address - Street 1:1501 DELL RANGE BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4853
Practice Address - Country:US
Practice Address - Phone:307-635-5854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3153183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist