Provider Demographics
NPI:1992387153
Name:FAKUADE, OLAYINKA CHARLES
Entity Type:Individual
Prefix:
First Name:OLAYINKA
Middle Name:CHARLES
Last Name:FAKUADE
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 1:4804 RABBIT TRL
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-8333
Mailing Address - Country:US
Mailing Address - Phone:972-333-5978
Mailing Address - Fax:
Practice Address - Street 1:500 N GALLOWAY AVE
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-3419
Practice Address - Country:US
Practice Address - Phone:972-288-4485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02219600183500000X
TX36678183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist