Healthcare Provider Details

I. General information

NPI: 1003053661
Provider Name (Legal Business Name): FESTUS OGUNBANJO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2009
Last Update Date: 10/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 NEWKIRK AVE
BROOKLYN NY
11226-6522
US

IV. Provider business mailing address

93 WILSON AVE
PARLIN NJ
08859-1669
US

V. Phone/Fax

Practice location:
  • Phone: 718-434-0391
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI02186000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: