Provider Demographics
NPI:1821302084
Name:MBAH, SIDNEY C
Entity Type:Individual
Prefix:
First Name:SIDNEY
Middle Name:C
Last Name:MBAH
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 1:752 HELLERMAN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-5316
Mailing Address - Country:US
Mailing Address - Phone:215-745-5378
Mailing Address - Fax:
Practice Address - Street 1:1401 W CHELTENHAM AVE
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:PA
Practice Address - Zip Code:19027-3131
Practice Address - Country:US
Practice Address - Phone:215-782-8950
Practice Address - Fax:215-782-8357
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP045105L183500000X
DEA1-0003090183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist