Healthcare Provider Details

I. General information

NPI: 1396024709
Provider Name (Legal Business Name): MUTIU OLUSEYI OKANLAWON R.PH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2011
Last Update Date: 08/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CORNER OF ROUTE12 & 7
FORT DEFIANCE AZ
86504
US

IV. Provider business mailing address

PO BOX 1263
FORT DEFIANCE AZ
86504-1263
US

V. Phone/Fax

Practice location:
  • Phone: 928-729-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number20174
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: