Provider Demographics
NPI:1366920381
Name:TUBY-LUKAN, ENIOLA BISOLA
Entity type:Individual
Prefix:
First Name:ENIOLA
Middle Name:BISOLA
Last Name:TUBY-LUKAN
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 1:130 HARVARD ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-7903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:270 UNION ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1348
Practice Address - Country:US
Practice Address - Phone:781-593-4805
Practice Address - Fax:781-593-5275
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHPHCY-04475183500000X
MAPH238651183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist