Provider Demographics
NPI:1205056348
Name:BOODOO, ERICA DEBRA (CHPT)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:DEBRA
Last Name:BOODOO
Suffix:
Gender:F
Credentials:CHPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 BONSAL STREET
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224
Mailing Address - Country:US
Mailing Address - Phone:443-846-2111
Mailing Address - Fax:
Practice Address - Street 1:2250 HICKORY ROAD
Practice Address - Street 2:SUITE 240
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462
Practice Address - Country:US
Practice Address - Phone:800-879-4471
Practice Address - Fax:610-834-7525
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD380100106111057183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician