=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407040389
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASMIR I. OGBONNA PHARMD,MBA, BCPS,CGP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2007
-----------------------------------------------------
Last Update Date | 12/31/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9300 DEWITT LOOP WTU WARRIOR CLINIC
-----------------------------------------------------
City | FORT BELVOIR
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22060-5285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-231-3224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9300 DEWITT LOOP WTU WARRIOR CLINIC
-----------------------------------------------------
City | FORT BELVOIR
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22060-5285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-231-3224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | 28RI03191900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1835P1200X
-----------------------------------------------------
Taxonomy Name | Pharmacotherapy Pharmacist
-----------------------------------------------------
License Number | RP441822
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------