Provider Demographics
NPI:1285901314
Name:MGBEJUME, ONYEIJEN
Entity type:Individual
Prefix:
First Name:ONYEIJEN
Middle Name:
Last Name:MGBEJUME
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 HALLVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06070-1867
Mailing Address - Country:US
Mailing Address - Phone:860-217-1174
Mailing Address - Fax:
Practice Address - Street 1:674 FAMINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119
Practice Address - Country:US
Practice Address - Phone:860-523-5849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT10053183500000X
MEPR5127183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist