Provider Demographics
NPI:1861987208
Name:NGANSOP, LIONEL N (PHARMD)
Entity type:Individual
Prefix:
First Name:LIONEL
Middle Name:N
Last Name:NGANSOP
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 1:150 WESTERN AVE NW
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-4504
Mailing Address - Country:US
Mailing Address - Phone:507-332-0084
Mailing Address - Fax:
Practice Address - Street 1:150 WESTERN AVE NW
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-4504
Practice Address - Country:US
Practice Address - Phone:507-332-0084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-103509183500000X
MI5302046629183500000X
MN125035183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist