Healthcare Provider Details

I. General information

NPI: 1588003073
Provider Name (Legal Business Name): AJIBOLA AFOLABI FAJIMOLU PHARM D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4415 DOUGLAS AVE
DES MOINES IA
50310-2717
US

IV. Provider business mailing address

245 24TH ST
WEST DES MOINES IA
50265-6226
US

V. Phone/Fax

Practice location:
  • Phone: 515-279-4739
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number21660
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: