Healthcare Provider Details

I. General information

NPI: 1881943793
Provider Name (Legal Business Name): RAPHAEL TAIWO OGUNSUSI PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2012
Last Update Date: 09/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 WELLINGTON WAY SE
CONYERS GA
30013-6413
US

IV. Provider business mailing address

2630 WELLINGTON WAY SE
CONYERS GA
30013-6413
US

V. Phone/Fax

Practice location:
  • Phone: 678-478-9511
  • Fax:
Mailing address:
  • Phone: 678-478-9511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number13344
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: