Healthcare Provider Details

I. General information

NPI: 1821648866
Provider Name (Legal Business Name): OMOTAYO LASEAN OLOWOLAYEMO PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2019
Last Update Date: 09/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5403A ANNAPOLIS RD
BLADENSBURG MD
20710-2201
US

IV. Provider business mailing address

4506 VALIANT TRCE
BOWIE MD
20720-4678
US

V. Phone/Fax

Practice location:
  • Phone: 301-277-7107
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26683
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: