Provider Demographics
NPI:1174028310
Name:OMODARA, OLUFEMI A (RPH)
Entity Type:Individual
Prefix:MRS
First Name:OLUFEMI
Middle Name:A
Last Name:OMODARA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 5693
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85042
Mailing Address - Country:US
Mailing Address - Phone:623-521-5935
Mailing Address - Fax:602-441-4838
Practice Address - Street 1:7227 S. CENTRAL AVE
Practice Address - Street 2:#1080
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042
Practice Address - Country:US
Practice Address - Phone:602-441-3564
Practice Address - Fax:602-441-4838
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ511406183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist