Provider Demographics
NPI:1154096246
Name:FAMILUSI, BOLUWATIFE (PHARMD)
Entity Type:Individual
Prefix:
First Name:BOLUWATIFE
Middle Name:
Last Name:FAMILUSI
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 WHARTON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-4231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 CAPITAL WAY
Practice Address - Street 2:
Practice Address - City:PENNINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08534-2520
Practice Address - Country:US
Practice Address - Phone:516-983-6042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI041915001835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Multi-Specialty