Provider Demographics
NPI:1699378943
Name:OMOSA, TOLUWALOPE
Entity Type:Individual
Prefix:
First Name:TOLUWALOPE
Middle Name:
Last Name:OMOSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2458 CANDLER RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-6411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2458 CANDLER RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-6411
Practice Address - Country:US
Practice Address - Phone:404-284-9350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61172183500000X
GARPH031803183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist