Provider Demographics
NPI:1861713042
Name:MAGOMNANG, MAYMONA (RPH)
Entity type:Individual
Prefix:
First Name:MAYMONA
Middle Name:
Last Name:MAGOMNANG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42841 INCANTATA PL
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92203-2969
Mailing Address - Country:US
Mailing Address - Phone:760-774-4582
Mailing Address - Fax:
Practice Address - Street 1:39155 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-1259
Practice Address - Country:US
Practice Address - Phone:760-772-7075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63473183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist