Provider Demographics
NPI:1578854311
Name:ILESANMI, ONILEOLA MAYOWA
Entity Type:Individual
Prefix:
First Name:ONILEOLA
Middle Name:MAYOWA
Last Name:ILESANMI
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 1:2916A RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-1724
Mailing Address - Country:US
Mailing Address - Phone:360-977-3773
Mailing Address - Fax:
Practice Address - Street 1:1200 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-1853
Practice Address - Country:US
Practice Address - Phone:360-807-2014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-27
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60042077183500000X
ORRPH-0012095183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist