Provider Demographics
NPI:1326650938
Name:OTUBANJO, OLUWAGBEMIGA ADEIFE
Entity Type:Individual
Prefix:
First Name:OLUWAGBEMIGA
Middle Name:ADEIFE
Last Name:OTUBANJO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 BAYLOR DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76010-4232
Mailing Address - Country:US
Mailing Address - Phone:682-597-1252
Mailing Address - Fax:
Practice Address - Street 1:1800 BAYLOR DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76010-4232
Practice Address - Country:US
Practice Address - Phone:682-597-1252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX661071835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist