Provider Demographics
NPI:1013310325
Name:ASIRU-BALOGUN, HABEEB (PHARMD)
Entity Type:Individual
Prefix:
First Name:HABEEB
Middle Name:
Last Name:ASIRU-BALOGUN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2859 FAIRLANE DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30340-3229
Mailing Address - Country:US
Mailing Address - Phone:404-202-3625
Mailing Address - Fax:
Practice Address - Street 1:2945 PANOLA RD
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-2313
Practice Address - Country:US
Practice Address - Phone:770-322-8486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH027854183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist