Provider Demographics
NPI:1902108012
Name:IGBODO, CHARLES E (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:E
Last Name:IGBODO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 16 WEXFORD TER
Mailing Address - Street 2:APT #3D
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-0000
Mailing Address - Country:US
Mailing Address - Phone:917-612-5651
Mailing Address - Fax:212-505-3724
Practice Address - Street 1:50 3RD AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-5529
Practice Address - Country:US
Practice Address - Phone:212-388-0340
Practice Address - Fax:212-505-3724
Is Sole Proprietor?:No
Enumeration Date:2010-11-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY39170183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY39170OtherNY PHARMACIST LICENCE