MEDICARE: MR. PETER EDIAGBONYA RPH

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	PS30313	FL

General Provider Information

NPI Number	:	1306980891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PETER EDIAGBONYA RPH

Provider Business Mailing Address
First Line	:	1012 EDGEWOOD AVE N
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32254-2324
Country	:	US
Telephone Number	:	904-695-2727
Fax Number	:	904-783-8151

Provider Business Practice Location Address
First Line	:	1012 EDGEWOOD AVE N
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32254-2324
Country	:	US
Telephone Number	:	904-695-2727
Fax Number	:	904-783-8151

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

Provider Enumeration Date	:	02/16/2007
Last Update Date	:	07/08/2007

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