Healthcare Provider Details

I. General information

NPI: 1205128378
Provider Name (Legal Business Name): AYODELLE SYPHAX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2011
Last Update Date: 05/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 WESTERN PKWY
WALDORF MD
20603-4582
US

IV. Provider business mailing address

609 AVIS DR
UPPER MARLBORO MD
20774-2283
US

V. Phone/Fax

Practice location:
  • Phone: 301-645-7580
  • Fax:
Mailing address:
  • Phone: 240-468-1292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number19568
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: