Provider Demographics
NPI:1063826576
Name:OSAYANDE, OMONYEMWEN
Entity Type:Individual
Prefix:
First Name:OMONYEMWEN
Middle Name:
Last Name:OSAYANDE
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 1:2506 E HILL RD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-5066
Mailing Address - Country:US
Mailing Address - Phone:810-606-1004
Mailing Address - Fax:810-606-1102
Practice Address - Street 1:2506 E HILL RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-5066
Practice Address - Country:US
Practice Address - Phone:810-606-1004
Practice Address - Fax:810-606-1102
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302038472183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist