Provider Demographics
NPI:1912372343
Name:AGBARA, IJEOMA
Entity Type:Individual
Prefix:
First Name:IJEOMA
Middle Name:
Last Name:AGBARA
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 1:5334 E CAPITOL ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-6611
Mailing Address - Country:US
Mailing Address - Phone:202-520-9264
Mailing Address - Fax:
Practice Address - Street 1:238 MCMECHEN ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-4301
Practice Address - Country:US
Practice Address - Phone:410-523-4704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23646183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist