Healthcare Provider Details

I. General information

NPI: 1326329814
Provider Name (Legal Business Name): IDAYAT ADEWUNMI PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2011
Last Update Date: 02/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6555 GREENE ST
PHILADELPHIA PA
19119-4051
US

IV. Provider business mailing address

6555 GREENE ST STE 3
PHILADELPHIA PA
19119-4040
US

V. Phone/Fax

Practice location:
  • Phone: 347-574-4754
  • Fax:
Mailing address:
  • Phone: 347-574-4754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP440061
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License NumberRP440061
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: