Provider Demographics
NPI:1003114166
Name:TAIWO, OLUWOLE T
Entity Type:Individual
Prefix:MR
First Name:OLUWOLE
Middle Name:T
Last Name:TAIWO
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 1:4637 HICKS RD SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-1333
Mailing Address - Country:US
Mailing Address - Phone:770-819-9177
Mailing Address - Fax:770-739-7732
Practice Address - Street 1:4637 HICKS RD SW
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-1333
Practice Address - Country:US
Practice Address - Phone:770-819-9177
Practice Address - Fax:770-739-7732
Is Sole Proprietor?:No
Enumeration Date:2011-03-14
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist