Provider Demographics
NPI:1972108736
Name:ADEBOWALE, GBOLAHAN
Entity type:Individual
Prefix:
First Name:GBOLAHAN
Middle Name:
Last Name:ADEBOWALE
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 1:1735 S HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-8941
Mailing Address - Country:US
Mailing Address - Phone:770-834-1010
Mailing Address - Fax:
Practice Address - Street 1:1735 S HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-8941
Practice Address - Country:US
Practice Address - Phone:770-834-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH027570183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist