Provider Demographics
NPI:1609246917
Name:FAIYENGO, OLIVE (PHARMD)
Entity Type:Individual
Prefix:
First Name:OLIVE
Middle Name:
Last Name:FAIYENGO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1916 STAGECOACH VLG
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72210-4775
Mailing Address - Country:US
Mailing Address - Phone:501-213-8130
Mailing Address - Fax:
Practice Address - Street 1:115 COMMONS DR
Practice Address - Street 2:
Practice Address - City:MAUMELLE
Practice Address - State:AR
Practice Address - Zip Code:72113-7266
Practice Address - Country:US
Practice Address - Phone:501-803-3274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD13284183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist