Provider Demographics
NPI:1689894537
Name:BALOGUN, ADEWALE DAVID (RPH)
Entity Type:Individual
Prefix:MR
First Name:ADEWALE
Middle Name:DAVID
Last Name:BALOGUN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3719 FAIRMONT DR
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-7141
Mailing Address - Country:US
Mailing Address - Phone:432-367-8727
Mailing Address - Fax:432-367-8727
Practice Address - Street 1:3719 FAIRMONT DR
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-7141
Practice Address - Country:US
Practice Address - Phone:432-367-8727
Practice Address - Fax:432-367-8727
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX377801835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy