MEDICARE: MAABO KLUDZE-FORSON 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	28RI03111100	NJ
2	183500000X	Pharmacist	051853	NY
3	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	051853	NY
4	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	28RI03111100	NJ

General Provider Information

NPI Number	:	1669763025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAABO KLUDZE-FORSON PHARMD

Provider Business Mailing Address
First Line	:	555 W 57TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10019-2925
Country	:	US
Telephone Number	:	212-506-5498
Fax Number	:

Provider Business Practice Location Address
First Line	:	555 W 57TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10019-2925
Country	:	US
Telephone Number	:	212-506-5498
Fax Number	:

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

Provider Enumeration Date	:	04/20/2011
Last Update Date	:	08/29/2012

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