Provider Demographics
NPI:1629212196
Name:OWOLABI, ALEXANDER OLUSOJI
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:OLUSOJI
Last Name:OWOLABI
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 1:10 PORT LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-1155
Mailing Address - Country:US
Mailing Address - Phone:973-546-9388
Mailing Address - Fax:
Practice Address - Street 1:435 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2356
Practice Address - Country:US
Practice Address - Phone:973-546-9388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-28
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02918500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist