Provider Demographics
NPI:1154978328
Name:AYEGBUSI, OLAIDE ISRAEL
Entity type:Individual
Prefix:
First Name:OLAIDE
Middle Name:ISRAEL
Last Name:AYEGBUSI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 MONTGOMERY ST APT B
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-3427
Mailing Address - Country:US
Mailing Address - Phone:240-360-7941
Mailing Address - Fax:
Practice Address - Street 1:7650 PORT CAPITAL DR
Practice Address - Street 2:
Practice Address - City:JESSUP
Practice Address - State:MD
Practice Address - Zip Code:20794-6793
Practice Address - Country:US
Practice Address - Phone:410-799-7770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD26738183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist