Healthcare Provider Details

I. General information

NPI: 1497965958
Provider Name (Legal Business Name): KAYODE AYODELE OLA RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2596 TINKLING SPRING RD
STUARTS DRAFT VA
24477-2706
US

IV. Provider business mailing address

141 JACKSON ST
BROADWAY VA
22815-9737
US

V. Phone/Fax

Practice location:
  • Phone: 540-337-2596
  • Fax:
Mailing address:
  • Phone: 540-560-5475
  • Fax: 540-908-2192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202207595
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: