Provider Demographics
NPI:1548747413
Name:ADEFARASIN, ABIODUN ADENUGA (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:ABIODUN
Middle Name:ADENUGA
Last Name:ADEFARASIN
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20746 MACK AVENUE
Mailing Address - Street 2:
Mailing Address - City:GROSS POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236
Mailing Address - Country:US
Mailing Address - Phone:313-640-9766
Mailing Address - Fax:313-640-9768
Practice Address - Street 1:20746 MACK AVENUE
Practice Address - Street 2:
Practice Address - City:GROSS POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236
Practice Address - Country:US
Practice Address - Phone:313-640-9766
Practice Address - Fax:313-640-9768
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302036644183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist