Healthcare Provider Details

I. General information

NPI: 1245729953
Provider Name (Legal Business Name): CIJO ANNIE EAPEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2018
Last Update Date: 05/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 BURMONT RD
DREXEL HILL PA
19026-4322
US

IV. Provider business mailing address

305 S PARKWAY APT 308B
BROOMALL PA
19008-3620
US

V. Phone/Fax

Practice location:
  • Phone: 610-626-4350
  • Fax: 610-626-2384
Mailing address:
  • Phone: 609-287-2557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP451326
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: