Healthcare Provider Details

I. General information

NPI: 1255797023
Provider Name (Legal Business Name): CLARA M OGUNDELE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CLARA M FAYOMI

II. Dates (important events)

Enumeration Date: 01/11/2016
Last Update Date: 01/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 7TH AVE STE 1700
FORT WORTH TX
76104-2733
US

IV. Provider business mailing address

PO BOX 99213
FORT WORTH TX
76199-0213
US

V. Phone/Fax

Practice location:
  • Phone: 682-885-3142
  • Fax: 682-885-6916
Mailing address:
  • Phone: 682-885-3622
  • Fax: 682-885-3936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number44515
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: