Healthcare Provider Details

I. General information

NPI: 1700332178
Provider Name (Legal Business Name): FUNMILAYO MUYIDE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 08/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 BROAD ROCK BLVD
RICHMOND VA
23249-0001
US

IV. Provider business mailing address

1201 BROAD ROCK BLVD
RICHMOND VA
23249-0001
US

V. Phone/Fax

Practice location:
  • Phone: 807-675-5000
  • Fax:
Mailing address:
  • Phone: 807-675-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License NumberPH235358
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: