Basic Information
| Provider Information | |||||||||
| NPI: | 1023612744 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEREPELE | ||||||||
| FirstName: | IMINABO | ||||||||
| MiddleName: | SAMSON | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3812 GILMER RD | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756041173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9034750477 | ||||||||
| FaxNumber: | 9034750478 | ||||||||
| Practice Location | |||||||||
| Address1: | 3812 GILMER RD | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756041173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9034750477 | ||||||||
| FaxNumber: | 9034750478 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2020 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P0018X | 54617 | TX | Y | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist |
No ID Information.