Healthcare Provider Details

I. General information

NPI: 1902289283
Provider Name (Legal Business Name): MODEBOLA OLOTU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2015
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19106 WAVERDALE CT
HOUSTON TX
77094-1135
US

IV. Provider business mailing address

19106 WAVERDALE CT
HOUSTON TX
77094-1135
US

V. Phone/Fax

Practice location:
  • Phone: 404-451-6662
  • Fax:
Mailing address:
  • Phone: 404-451-6662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number023860
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number18353
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number62344
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: