Healthcare Provider Details

I. General information

NPI: 1750291407
Provider Name (Legal Business Name): GRACE AWOLEYE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16750 COUNTY ROAD 30
MAPLE GROVE MN
55311-4523
US

IV. Provider business mailing address

10831 ITHACA LN N
MAPLE GROVE MN
55369-7542
US

V. Phone/Fax

Practice location:
  • Phone: 763-416-1863
  • Fax:
Mailing address:
  • Phone: 763-600-3448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number127522
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: