Healthcare Provider Details

I. General information

NPI: 1003632340
Provider Name (Legal Business Name): MOYOSORE A OGUNGBE RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2024
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12279 LAKE UNDERHILL RD
ORLANDO FL
32825-5010
US

IV. Provider business mailing address

5317 CURRY FORD RD APT N205
ORLANDO FL
32812-7210
US

V. Phone/Fax

Practice location:
  • Phone: 407-273-0817
  • Fax:
Mailing address:
  • Phone: 407-419-7710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS67957
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: