Healthcare Provider Details

I. General information

NPI: 1386504454
Provider Name (Legal Business Name): MICHAEL OGUNYEMI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2025
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14700 LAC LAVON DR
BURNSVILLE MN
55306-6398
US

IV. Provider business mailing address

14700 LAC LAVON DR
BURNSVILLE MN
55306-6398
US

V. Phone/Fax

Practice location:
  • Phone: 952-432-4471
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number815506
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: