Healthcare Provider Details

I. General information

NPI: 1316384217
Provider Name (Legal Business Name): KOLAWOLE A DUROJAIYE BSC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2013
Last Update Date: 05/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3752 W 16TH ST
CHICAGO IL
60623-2028
US

IV. Provider business mailing address

2601 W JEROME ST
CHICAGO IL
60645-1407
US

V. Phone/Fax

Practice location:
  • Phone: 773-521-0060
  • Fax: 773-521-8770
Mailing address:
  • Phone: 773-743-5593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051033951
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: