Provider Demographics
NPI:1598936296
Name:EGBUNINE, INNOCENT
Entity Type:Individual
Prefix:
First Name:INNOCENT
Middle Name:
Last Name:EGBUNINE
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 1:4304 MORAVIA RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-6411
Mailing Address - Country:US
Mailing Address - Phone:410-488-1610
Mailing Address - Fax:
Practice Address - Street 1:1447 YORK RD
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-6017
Practice Address - Country:US
Practice Address - Phone:410-339-5506
Practice Address - Fax:410-339-5650
Is Sole Proprietor?:No
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12461183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist