MEDICARE: ANTHONY O AJEGBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	0010521	CT

General Provider Information

NPI Number	:	1154832079
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTHONY O AJEGBA

Provider Business Mailing Address
First Line	:	27 BEECHER LN
Second Line	:
City	:	ROCKY HILL
State	:	CT
Zip	:	06067-3239
Country	:	US
Telephone Number	:	860-655-1988
Fax Number	:

Provider Business Practice Location Address
First Line	:	1156 ALBANY AVE
Second Line	:
City	:	HARTFORD
State	:	CT
Zip	:	06112-2393
Country	:	US
Telephone Number	:	860-206-3890
Fax Number	:	860-906-1428

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2017
Last Update Date	:	10/18/2017

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