Healthcare Provider Details

I. General information

NPI: 1043719958
Provider Name (Legal Business Name): ADENIKE FASAN B.PHARM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ADENIKE AKINBOWALE B.PHARM

II. Dates (important events)

Enumeration Date: 02/06/2018
Last Update Date: 02/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4525 CAMERON VALLEY PKWY
CHARLOTTE NC
28211-4369
US

IV. Provider business mailing address

1504 HUGH FOREST RD
CHARLOTTE NC
28270-9797
US

V. Phone/Fax

Practice location:
  • Phone: 980-442-9304
  • Fax:
Mailing address:
  • Phone: 980-442-9304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835X0200X
TaxonomyOncology Pharmacist
License Number23960
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: