Provider Demographics
NPI:1295034783
Name:AJIBADE, WURAOLA OLUBUNMI IDOWU (RPH)
Entity Type:Individual
Prefix:MRS
First Name:WURAOLA
Middle Name:OLUBUNMI IDOWU
Last Name:AJIBADE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:WURAOLA
Other - Middle Name:OLUBUNMI IDOWU
Other - Last Name:AJAYI-AJIBADE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:4694 FORSYTH RD
Mailing Address - Street 2:RITE AID
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-4420
Mailing Address - Country:US
Mailing Address - Phone:478-474-3077
Mailing Address - Fax:478-474-1759
Practice Address - Street 1:4694 FORSYTH RD
Practice Address - Street 2:RITE AID
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4420
Practice Address - Country:US
Practice Address - Phone:478-474-3077
Practice Address - Fax:478-474-1759
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA19479183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1659470821OtherNPI NUMBER