=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154832079
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTHONY O AJEGBA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2017
-----------------------------------------------------
Last Update Date | 10/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1156 ALBANY AVE
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06112-2393
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-206-3890
-----------------------------------------------------
Fax | 860-906-1428
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27 BEECHER LN
-----------------------------------------------------
City | ROCKY HILL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06067-3239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-655-1988
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 0010521
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------