Provider Demographics
NPI:1285238428
Name:AGBOOLA, FOLUSO
Entity type:Individual
Prefix:
First Name:FOLUSO
Middle Name:
Last Name:AGBOOLA
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 1:2830 N DRUID HILLS RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-3926
Mailing Address - Country:US
Mailing Address - Phone:404-679-4666
Mailing Address - Fax:
Practice Address - Street 1:2830 N DRUID HILLS RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-3926
Practice Address - Country:US
Practice Address - Phone:404-679-4666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021484183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist