Provider Demographics
NPI:1215229331
Name:ANTONISSEN, OLATUNBOSUN (RPH)
Entity Type:Individual
Prefix:MS
First Name:OLATUNBOSUN
Middle Name:
Last Name:ANTONISSEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MRS
Other - First Name:OLATUNBOSUN
Other - Middle Name:OLATOKUNBO
Other - Last Name:ANTONISSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:6805 PARKER FARM DR
Mailing Address - Street 2:ATTENTION: PHARMACY
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405-3168
Mailing Address - Country:US
Mailing Address - Phone:910-256-4159
Mailing Address - Fax:910-256-7868
Practice Address - Street 1:6805 PARKER FARM DR
Practice Address - Street 2:ATTENTION: PHARMACY
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-3168
Practice Address - Country:US
Practice Address - Phone:910-256-4159
Practice Address - Fax:910-256-7868
Is Sole Proprietor?:No
Enumeration Date:2011-05-08
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15694183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC15694OtherBOARD OF PHARMACY LISENCE NUMBER