Healthcare Provider Details

I. General information

NPI: 1710262407
Provider Name (Legal Business Name): ADEOLA EDEMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2011
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 N MAGNOLIA AVE STE 105
CLOVIS CA
93611-9205
US

IV. Provider business mailing address

3338 DUNCAN AVE
CLOVIS CA
93619-5007
US

V. Phone/Fax

Practice location:
  • Phone: 559-375-1241
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number63688
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: