MEDICARE: MR. KAYODE EBED-MELECH BALOGUN SR. R.PH.

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	RP033280R	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	RP033280R	OTHER	PA	PHARMACIST

General Provider Information

NPI Number	:	1598825598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KAYODE EBED-MELECH BALOGUN SR. R.PH.

Provider Business Mailing Address
First Line	:	2409 EDGMONT AVE
Second Line	:
City	:	CHESTER
State	:	PA
Zip	:	19013-4612
Country	:	US
Telephone Number	:	267-307-0104
Fax Number	:

Provider Business Practice Location Address
First Line	:	1111 AVENUE OF THE STATES
Second Line	:
City	:	CHESTER
State	:	PA
Zip	:	19013-5967
Country	:	US
Telephone Number	:	484-816-0344
Fax Number	:	484-816-0296

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

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	01/21/2022

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