Healthcare Provider Details

I. General information

NPI: 1285901314
Provider Name (Legal Business Name): ONYEIJEN MGBEJUME
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2011
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

674 FAMINGTON AVENUE
WEST HARTFORD CT
06119
US

IV. Provider business mailing address

7 HALLVIEW DR
SIMSBURY CT
06070-1867
US

V. Phone/Fax

Practice location:
  • Phone: 860-523-5849
  • Fax:
Mailing address:
  • Phone: 860-217-1174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPCT10053
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPR5127
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: