Provider Demographics
NPI:1548595853
Name:JOLAOGUN, OLUSOLA OMOTUNDE
Entity Type:Individual
Prefix:
First Name:OLUSOLA
Middle Name:OMOTUNDE
Last Name:JOLAOGUN
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 1:1385 E FLORENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-5318
Mailing Address - Country:US
Mailing Address - Phone:520-836-0901
Mailing Address - Fax:
Practice Address - Street 1:1385 E FLORENCE BLVD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-5318
Practice Address - Country:US
Practice Address - Phone:520-836-0901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS016986183500000X
FLPS35040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist