Provider Demographics
NPI:1497036412
Name:AJAGUNNA, ADEDOTUN (PHARMD, RPH)
Entity Type:Individual
Prefix:DR
First Name:ADEDOTUN
Middle Name:
Last Name:AJAGUNNA
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 CHAMPION LAKE BLVD
Mailing Address - Street 2:APT. 1609
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-3772
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6101 W 70TH ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-2507
Practice Address - Country:US
Practice Address - Phone:318-688-1448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-03
Last Update Date:2011-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA019279183500000X
TX49662183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist