MEDICARE: MR. JACOB ORITSENEMI UDUAGHAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	0202012619	VA

General Provider Information

NPI Number	:	1063726065
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACOB ORITSENEMI UDUAGHAN

Provider Business Mailing Address
First Line	:	5795 PRINCESS ANNE RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-3224
Country	:	US
Telephone Number	:	757-490-0307
Fax Number	:

Provider Business Practice Location Address
First Line	:	5795 PRINCESS ANNE RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-3224
Country	:	US
Telephone Number	:	757-490-0307
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2010
Last Update Date	:	08/02/2010

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Directions to “ MR. JACOB ORITSENEMI UDUAGHAN ” Practice Location

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