Provider Demographics
NPI:1457748782
Name:FADEYI, ALLEGRA VANESSA MCDONALD (PHARMD, CGP)
Entity Type:Individual
Prefix:
First Name:ALLEGRA
Middle Name:VANESSA MCDONALD
Last Name:FADEYI
Suffix:
Gender:F
Credentials:PHARMD, CGP
Other - Prefix:
Other - First Name:ALLEGRA
Other - Middle Name:
Other - Last Name:MCDONALD FADEYI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:643 ROCKY FIELD DRIVE
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-6550
Mailing Address - Country:US
Mailing Address - Phone:804-651-6429
Mailing Address - Fax:
Practice Address - Street 1:643 ROCKY FIELD DR
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-6550
Practice Address - Country:US
Practice Address - Phone:804-651-6429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN360051835G0303X
MSP-117281835G0303X
VA02022052621835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric