Healthcare Provider Details

I. General information

NPI: 1053275834
Provider Name (Legal Business Name): MARY SIMISOLA OGUNMERU PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 MARCELA DR.
WILLITS CA
95490
US

IV. Provider business mailing address

2601 MCBRIDE LN APT 18
SANTA ROSA CA
95403-2733
US

V. Phone/Fax

Practice location:
  • Phone: 707-456-3005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number91386
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: