Healthcare Provider Details

I. General information

NPI: 1184396830
Provider Name (Legal Business Name): OLABODE PETER OLUKANNI PHARM D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 10/01/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 WHITLEY AVE
CORCORAN CA
93212-2226
US

IV. Provider business mailing address

906 WHISTLING DUCK DR
UPPER MARLBORO MD
20774-7146
US

V. Phone/Fax

Practice location:
  • Phone: 559-992-8020
  • Fax:
Mailing address:
  • Phone: 301-875-9547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRPH85319
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: