Provider Demographics
NPI:1063795755
Name:EGBUCHULAM, KEZIE ADAKU (RPH)
Entity type:Individual
Prefix:
First Name:KEZIE
Middle Name:ADAKU
Last Name:EGBUCHULAM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 FARBER HILL RD
Mailing Address - Street 2:
Mailing Address - City:BOONTON TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:07005-9223
Mailing Address - Country:US
Mailing Address - Phone:973-265-4479
Mailing Address - Fax:
Practice Address - Street 1:600 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:BOONTON
Practice Address - State:NJ
Practice Address - Zip Code:07005-1940
Practice Address - Country:US
Practice Address - Phone:973-939-9021
Practice Address - Fax:973-939-2368
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02485100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist