Healthcare Provider Details

I. General information

NPI: 1407131311
Provider Name (Legal Business Name): MAVIS YEBOAH PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 10/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 W NORTHERN PKWY
BALTIMORE MD
21215-4412
US

IV. Provider business mailing address

4025 W NORTHERN PKWY
BALTIMORE MD
21215-4412
US

V. Phone/Fax

Practice location:
  • Phone: 410-764-9570
  • Fax:
Mailing address:
  • Phone: 410-764-9570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number19986
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: