MEDICARE: DR. CHIMDIMMA ILONZO PHARM.D.

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	RP442458	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	RP442458	OTHER	PA	PA BOARD OF PHARMACY

General Provider Information

NPI Number	:	1548588205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHIMDIMMA ILONZO PHARM.D.

Provider Business Mailing Address
First Line	:	1154 BALTIMORE PIKE
Second Line	:
City	:	SPRINGFIELD
State	:	PA
Zip	:	19064-2850
Country	:	US
Telephone Number	:	610-544-4645
Fax Number	:	610-544-1757

Provider Business Practice Location Address
First Line	:	1154 BALTIMORE PIKE
Second Line	:
City	:	SPRINGFIELD
State	:	PA
Zip	:	19064-2850
Country	:	US
Telephone Number	:	610-544-4645
Fax Number	:	610-544-1757

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

Provider Enumeration Date	:	05/05/2010
Last Update Date	:	09/10/2012

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