Provider Demographics
NPI:1730464421
Name:MBOMNDA, JUDE-THADDEUS TARJOMKAM (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JUDE-THADDEUS
Middle Name:TARJOMKAM
Last Name:MBOMNDA
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 1:4980 SPRINGFIELD ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45431-1186
Mailing Address - Country:US
Mailing Address - Phone:614-218-2323
Mailing Address - Fax:
Practice Address - Street 1:4881 SUGARMAPLE ROAD
Practice Address - Street 2:88MDG/SGQP WRIGHT PATTERSON AFB OH 45433
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:45433
Practice Address - Country:US
Practice Address - Phone:937-257-9014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03129855183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist