MEDICARE: MMOA TCHONI AGBERE PHARMD

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	050561	NY
2	183500000X	Pharmacist	0010935	CT

General Provider Information

NPI Number	:	1326366634
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MMOA TCHONI AGBERE PHARMD

Provider Business Mailing Address
First Line	:	77 PARK ST
Second Line	:
City	:	STRATFORD
State	:	CT
Zip	:	06614-4051
Country	:	US
Telephone Number	:	203-870-4636
Fax Number	:	718-665-6771

Provider Business Practice Location Address
First Line	:	542 SOUTHERN BLVD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10455-3715
Country	:	US
Telephone Number	:	718-665-6771
Fax Number	:	718-665-1044

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

Provider Enumeration Date	:	05/11/2010
Last Update Date	:	05/11/2010

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