Healthcare Provider Details

I. General information

NPI: 1629212196
Provider Name (Legal Business Name): ALEXANDER OLUSOJI OWOLABI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2009
Last Update Date: 04/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 LEXINGTON AVE
CLIFTON NJ
07011-2356
US

IV. Provider business mailing address

10 PORT LN
STATEN ISLAND NY
10302-1155
US

V. Phone/Fax

Practice location:
  • Phone: 973-546-9388
  • Fax:
Mailing address:
  • Phone: 973-546-9388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI02918500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: