Provider Demographics
NPI:1669010336
Name:MGBEOJIRIKWE, CYNTHIA CHISOM
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:CHISOM
Last Name:MGBEOJIRIKWE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT CHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10573-4210
Mailing Address - Country:US
Mailing Address - Phone:914-937-1580
Mailing Address - Fax:
Practice Address - Street 1:107 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT CHESTER
Practice Address - State:NY
Practice Address - Zip Code:10573-4210
Practice Address - Country:US
Practice Address - Phone:914-934-1580
Practice Address - Fax:914-934-1586
Is Sole Proprietor?:No
Enumeration Date:2019-12-12
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066423183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1669010336Medicaid