Provider Demographics
NPI:1386928653
Name:EGBE, GWENDOLINE TAKOR
Entity type:Individual
Prefix:
First Name:GWENDOLINE
Middle Name:TAKOR
Last Name:EGBE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GWENDOLINE
Other - Middle Name:NCHONG
Other - Last Name:TAKOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1260 LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-7928
Mailing Address - Country:US
Mailing Address - Phone:301-404-0379
Mailing Address - Fax:410-795-6832
Practice Address - Street 1:1260 LIBERTY RD
Practice Address - Street 2:
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-7928
Practice Address - Country:US
Practice Address - Phone:410-795-2968
Practice Address - Fax:410-795-6832
Is Sole Proprietor?:No
Enumeration Date:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14623183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist