Healthcare Provider Details

I. General information

NPI: 1699450619
Provider Name (Legal Business Name): OLALEKA JOSEPH OGUNTOBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 06/19/2023
Certification Date: 06/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 N SAN PEDRO RD
SAN RAFAEL CA
94903-2858
US

IV. Provider business mailing address

234 N SAN PEDRO RD
SAN RAFAEL CA
94903-2858
US

V. Phone/Fax

Practice location:
  • Phone: 415-479-3450
  • Fax:
Mailing address:
  • Phone: 415-479-3450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number82213
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: