Healthcare Provider Details

I. General information

NPI: 1164304382
Provider Name (Legal Business Name): KAMIL AYODAPO FAGBENRO PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2025
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 ULSTER AVE
KINGSTON NY
12401-1514
US

IV. Provider business mailing address

97 PINEHURST AVE
ALBANY NY
12203-2525
US

V. Phone/Fax

Practice location:
  • Phone: 845-336-5955
  • Fax:
Mailing address:
  • Phone: 516-838-9982
  • Fax: 516-838-9982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number072260
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: