Provider Demographics
NPI:1760930432
Name:ADETOLA, FAROOQ
Entity Type:Individual
Prefix:MR
First Name:FAROOQ
Middle Name:
Last Name:ADETOLA
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 1:10800 CLIPPER CIR
Mailing Address - Street 2:
Mailing Address - City:PRINCESS ANNE
Mailing Address - State:MD
Mailing Address - Zip Code:21853-4318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2440 CENTREVILLE RD
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MD
Practice Address - Zip Code:21617-2802
Practice Address - Country:US
Practice Address - Phone:443-262-9640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24407183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist