Provider Demographics
NPI:1619974003
Name:FADEYI, MICHAEL O (MS, PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:O
Last Name:FADEYI
Suffix:
Gender:M
Credentials:MS, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2860 CONCHO TRL
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76118-7395
Mailing Address - Country:US
Mailing Address - Phone:817-726-2498
Mailing Address - Fax:817-589-1213
Practice Address - Street 1:6310 SOUTHWEST BLVD STE 204
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76109-6916
Practice Address - Country:US
Practice Address - Phone:866-869-7307
Practice Address - Fax:817-263-1116
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26313183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist