Healthcare Provider Details

I. General information

NPI: 1063826576
Provider Name (Legal Business Name): OMONYEMWEN OSAYANDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2014
Last Update Date: 06/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2506 E HILL RD
GRAND BLANC MI
48439-5066
US

IV. Provider business mailing address

2506 E HILL RD
GRAND BLANC MI
48439-5066
US

V. Phone/Fax

Practice location:
  • Phone: 810-606-1004
  • Fax: 810-606-1102
Mailing address:
  • Phone: 810-606-1004
  • Fax: 810-606-1102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302038472
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: