MEDICARE: SIDNEY C MBAH

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	RP045105L	PA
2	183500000X	Pharmacist	A1-0003090	DE

General Provider Information

NPI Number	:	1821302084
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SIDNEY C MBAH

Provider Business Mailing Address
First Line	:	752 HELLERMAN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19111-5316
Country	:	US
Telephone Number	:	215-745-5378
Fax Number	:

Provider Business Practice Location Address
First Line	:	1401 W CHELTENHAM AVE
Second Line	:
City	:	MELROSE PARK
State	:	PA
Zip	:	19027-3131
Country	:	US
Telephone Number	:	215-782-8950
Fax Number	:	215-782-8357

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

Provider Enumeration Date	:	07/29/2010
Last Update Date	:	07/29/2010

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Directions to “ SIDNEY C MBAH ” Practice Location

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