Provider Demographics
NPI:1306639166
Name:OMOFOMWAN, OSARO ANTONY
Entity type:Individual
Prefix:
First Name:OSARO
Middle Name:ANTONY
Last Name:OMOFOMWAN
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 1:2228 TIMBERS DR
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-2228
Mailing Address - Country:US
Mailing Address - Phone:504-799-9581
Mailing Address - Fax:
Practice Address - Street 1:2001 CAROL SUE AVE
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-4445
Practice Address - Country:US
Practice Address - Phone:504-366-1535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-26
Last Update Date:2025-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.025738183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist