Provider Demographics
NPI:1104424944
Name:OYEWOLE, OLUWABUKUNMI ELIJAH (RPH)
Entity type:Individual
Prefix:
First Name:OLUWABUKUNMI
Middle Name:ELIJAH
Last Name:OYEWOLE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:BUKUNMI
Other - Middle Name:ELIJAH
Other - Last Name:OYEWOLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:909 HARVEST BROOK DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-7543
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2175 PARKLAKE DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-2845
Practice Address - Country:US
Practice Address - Phone:770-469-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH032354183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty