Provider Demographics
NPI:1205128378
Name:SYPHAX, AYODELLE
Entity type:Individual
Prefix:
First Name:AYODELLE
Middle Name:
Last Name:SYPHAX
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 1:609 AVIS DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-2283
Mailing Address - Country:US
Mailing Address - Phone:240-468-1292
Mailing Address - Fax:
Practice Address - Street 1:3300 WESTERN PKWY
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4582
Practice Address - Country:US
Practice Address - Phone:301-645-7580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-09
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19568183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist