Provider Demographics
NPI:1750715363
Name:AGBORTOKO, BREANNA A (PHARMD)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:A
Last Name:AGBORTOKO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 DINGLEY CT APT 1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3301
Mailing Address - Country:US
Mailing Address - Phone:207-626-0364
Mailing Address - Fax:
Practice Address - Street 1:417 PAYNE RD
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-9594
Practice Address - Country:US
Practice Address - Phone:207-510-3005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-30
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR12969183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist