Provider Demographics
NPI:1174493183
Name:FAKOYA, SIMISOLA AJIBOLA
Entity type:Individual
Prefix:
First Name:SIMISOLA
Middle Name:AJIBOLA
Last Name:FAKOYA
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 1:175 41ST ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5206
Mailing Address - Country:US
Mailing Address - Phone:510-658-3496
Mailing Address - Fax:510-658-0772
Practice Address - Street 1:175 41ST ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5206
Practice Address - Country:US
Practice Address - Phone:510-658-3496
Practice Address - Fax:510-658-0772
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-06
Last Update Date:2025-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53199183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty