Provider Demographics
NPI:1942447198
Name:GBADAMOSI, GRACE TITILOLA (RPH)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:TITILOLA
Last Name:GBADAMOSI
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 144
Mailing Address - Street 2:
Mailing Address - City:DIANA
Mailing Address - State:TX
Mailing Address - Zip Code:75640-0144
Mailing Address - Country:US
Mailing Address - Phone:430-625-2600
Mailing Address - Fax:
Practice Address - Street 1:1970 US HIGHWAY 259 S # 100
Practice Address - Street 2:
Practice Address - City:DIANA
Practice Address - State:TX
Practice Address - Zip Code:75640-4037
Practice Address - Country:US
Practice Address - Phone:430-625-2600
Practice Address - Fax:430-625-2030
Is Sole Proprietor?:No
Enumeration Date:2009-01-09
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPH100000271183500000X
MD14130183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist