Healthcare Provider Details

I. General information

NPI: 1891070587
Provider Name (Legal Business Name): ALAB OGUNBADENIYI B.PHARM., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2011
Last Update Date: 10/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6665 HIGHWAY 85
RIVERDALE GA
30274-2346
US

IV. Provider business mailing address

6665 HIGHWAY 85
RIVERDALE GA
30274-2346
US

V. Phone/Fax

Practice location:
  • Phone: 770-907-6934
  • Fax: 770-907-6940
Mailing address:
  • Phone: 770-907-6934
  • Fax: 770-907-6940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH025178
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202207856
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: