Healthcare Provider Details

I. General information

NPI: 1811310196
Provider Name (Legal Business Name): OMODELE AKINGBOYE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2014
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 EASTCHESTER RD
BRONX NY
10461-2301
US

IV. Provider business mailing address

5 LYNHAVEN DR
NEW CITY NY
10956-2422
US

V. Phone/Fax

Practice location:
  • Phone: 718-904-2838
  • Fax: 718-904-3363
Mailing address:
  • Phone: 718-904-2838
  • Fax: 718-904-3363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number032884-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: