Provider Demographics
NPI:1386074631
Name:ADERETI, MODUPEOLA O
Entity type:Individual
Prefix:MRS
First Name:MODUPEOLA
Middle Name:O
Last Name:ADERETI
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 1:5500 KNOLL NORTH DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-2370
Mailing Address - Country:US
Mailing Address - Phone:443-810-2001
Mailing Address - Fax:443-810-2101
Practice Address - Street 1:5500 KNOLL NORTH DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2370
Practice Address - Country:US
Practice Address - Phone:443-810-2001
Practice Address - Fax:443-810-2101
Is Sole Proprietor?:No
Enumeration Date:2013-11-23
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18109183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist