Healthcare Provider Details

I. General information

NPI: 1124620224
Provider Name (Legal Business Name): OMOBOLANLE M ESAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2020
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6405 MIRA MESA BLVD STE 210
SAN DIEGO CA
92121-4146
US

IV. Provider business mailing address

3820 43RD ST APT 3
SAN DIEGO CA
92105-2674
US

V. Phone/Fax

Practice location:
  • Phone: 866-701-6565
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number83472
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: