Healthcare Provider Details

I. General information

NPI: 1821302084
Provider Name (Legal Business Name): SIDNEY C MBAH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2010
Last Update Date: 07/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 W CHELTENHAM AVE
MELROSE PARK PA
19027-3131
US

IV. Provider business mailing address

752 HELLERMAN ST
PHILADELPHIA PA
19111-5316
US

V. Phone/Fax

Practice location:
  • Phone: 215-782-8950
  • Fax: 215-782-8357
Mailing address:
  • Phone: 215-745-5378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP045105L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberA1-0003090
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: