Provider Demographics
NPI:1922418110
Name:AGBORTOKO, RICHARD TANYI (PHARMD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:TANYI
Last Name:AGBORTOKO
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 1:62 LELAND ST
Mailing Address - Street 2:APARTMENT 1
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2528
Mailing Address - Country:US
Mailing Address - Phone:617-794-0293
Mailing Address - Fax:
Practice Address - Street 1:616 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-1510
Practice Address - Country:US
Practice Address - Phone:207-761-9454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-28
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR12976183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist