=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396231437
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ADESAYO OLAWALE AKINSANYA PHARM D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2018
-----------------------------------------------------
Last Update Date | 01/07/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2608 ROUTE 112
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11763-2578
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-475-4476
-----------------------------------------------------
Fax | 631-475-4288
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 52 MONROE ST
-----------------------------------------------------
City | FRANKLIN SQUARE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11010-3621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-668-2425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | 064086
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | I064086
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------