Provider Demographics
NPI:1104132075
Name:ODUSANYA, ADEPERO ENITAN
Entity type:Individual
Prefix:
First Name:ADEPERO
Middle Name:ENITAN
Last Name:ODUSANYA
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 1:6806 RIVERDALE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-1802
Mailing Address - Country:US
Mailing Address - Phone:301-429-9122
Mailing Address - Fax:301-429-9286
Practice Address - Street 1:6806 RIVERDALE RD
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-1802
Practice Address - Country:US
Practice Address - Phone:301-429-9122
Practice Address - Fax:301-429-9286
Is Sole Proprietor?:No
Enumeration Date:2010-08-29
Last Update Date:2010-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17825183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist