Provider Demographics
NPI:1184017766
Name:ADETIFA, WILLIAM (BS PHARM, MBA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:ADETIFA
Suffix:
Gender:M
Credentials:BS PHARM, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 S KINGSHIGHWAY ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-5742
Mailing Address - Country:US
Mailing Address - Phone:573-339-1700
Mailing Address - Fax:573-339-7319
Practice Address - Street 1:1 S KINGSHIGHWAY ST
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5742
Practice Address - Country:US
Practice Address - Phone:573-339-1700
Practice Address - Fax:573-339-7319
Is Sole Proprietor?:No
Enumeration Date:2015-03-06
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010014025183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist