Provider Demographics
NPI:1063003853
Name:CHUKWU, CHIMAOBI
Entity Type:Individual
Prefix:
First Name:CHIMAOBI
Middle Name:
Last Name:CHUKWU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 MICHELLE LN
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-1526
Mailing Address - Country:US
Mailing Address - Phone:617-291-8144
Mailing Address - Fax:857-308-3440
Practice Address - Street 1:278 BLUE HILL AVE
Practice Address - Street 2:ST. 288
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02119
Practice Address - Country:US
Practice Address - Phone:617-652-7679
Practice Address - Fax:857-308-3440
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH235477183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPH235477OtherPHARMACIST LICENSE NUMBER