MEDICARE: BOGHOS YEDIKIAN PHARMD

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	28RI04003300	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	28RI04003300	OTHER	NJ	NEW JERSEY BOARD OF PHARMACY

General Provider Information

NPI Number	:	1760041842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BOGHOS YEDIKIAN PHARMD

Provider Business Mailing Address
First Line	:	197 OXFORD RD
Second Line	:
City	:	CHESTER
State	:	NY
Zip	:	10918-4406
Country	:	US
Telephone Number	:	201-994-9651
Fax Number	:

Provider Business Practice Location Address
First Line	:	341 BROAD AVE
Second Line	:
City	:	PALISADES PARK
State	:	NJ
Zip	:	07650-1656
Country	:	US
Telephone Number	:	201-944-2720
Fax Number	:

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

Provider Enumeration Date	:	06/11/2019
Last Update Date	:	06/11/2019

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