Provider Demographics
NPI:1063724615
Name:ILORI, OLUSOLA ADEBOWALE
Entity type:Individual
Prefix:MRS
First Name:OLUSOLA
Middle Name:ADEBOWALE
Last Name:ILORI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:592 SILVERWOOD ST
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-8963
Mailing Address - Country:US
Mailing Address - Phone:619-421-5134
Mailing Address - Fax:
Practice Address - Street 1:1501 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-2211
Practice Address - Country:US
Practice Address - Phone:619-421-5134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-12
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62067183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist