Provider Demographics
NPI:1326366634
Name:AGBERE, MMOA TCHONI (PHARMD)
Entity Type:Individual
Prefix:
First Name:MMOA
Middle Name:TCHONI
Last Name:AGBERE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 PARK ST
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-4051
Mailing Address - Country:US
Mailing Address - Phone:203-870-4636
Mailing Address - Fax:718-665-6771
Practice Address - Street 1:542 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-3715
Practice Address - Country:US
Practice Address - Phone:718-665-6771
Practice Address - Fax:718-665-1044
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050561183500000X
CT0010935183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist