Provider Demographics
NPI:1962950873
Name:OKEBIORUN, EDWARD O
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:O
Last Name:OKEBIORUN
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 1:3204 KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-1918
Mailing Address - Country:US
Mailing Address - Phone:215-427-1603
Mailing Address - Fax:
Practice Address - Street 1:3204 KENSINGTON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-1918
Practice Address - Country:US
Practice Address - Phone:215-427-1603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-20
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP446578183500000X
NJ28RI02694100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist