Healthcare Provider Details

I. General information

NPI: 1730464421
Provider Name (Legal Business Name): JUDE-THADDEUS TARJOMKAM MBOMNDA PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2011
Last Update Date: 10/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGARMAPLE ROAD 88MDG/SGQP WRIGHT PATTERSON AFB OH 45433
FPO AP
45433
US

IV. Provider business mailing address

4980 SPRINGFIELD ST
DAYTON OH
45431-1186
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-9014
  • Fax:
Mailing address:
  • Phone: 614-218-2323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03129855
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: