Healthcare Provider Details

I. General information

NPI: 1427879956
Provider Name (Legal Business Name): DR. OLAWUMI IKEADE OGEDENGBE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2024
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 ANDREWS AVE
OZARK AL
36360-0404
US

IV. Provider business mailing address

10 GIBSON ST
FORT NOVOSEL AL
36362-2226
US

V. Phone/Fax

Practice location:
  • Phone: 334-774-2654
  • Fax:
Mailing address:
  • Phone: 612-222-2685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number23767
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: