Provider Demographics
NPI:1316447097
Name:OLANIYAN, LATEEF AJANI
Entity type:Individual
Prefix:DR
First Name:LATEEF
Middle Name:AJANI
Last Name:OLANIYAN
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 1:2709 W BROADWAY AVENUE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837
Mailing Address - Country:US
Mailing Address - Phone:509-765-9332
Mailing Address - Fax:509-765-4761
Practice Address - Street 1:2709 W BROADWAY AVENUE
Practice Address - Street 2:SOUTHGATE PHARMACY
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837
Practice Address - Country:US
Practice Address - Phone:509-765-9332
Practice Address - Fax:509-765-4761
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00016055183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist