Healthcare Provider Details

I. General information

NPI: 1184255341
Provider Name (Legal Business Name): GRACE ABIMBOLA AKINYEMI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2020
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 CROSSING PL APT 131A
AUSTIN TX
78741-1804
US

IV. Provider business mailing address

1301 CROSSING PL APT 131A
AUSTIN TX
78741-1804
US

V. Phone/Fax

Practice location:
  • Phone: 832-428-5630
  • Fax:
Mailing address:
  • Phone: 832-428-5630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number30014538
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: