Provider Demographics
NPI:1669559696
Name:ADETULA, MICHAEL O (PHD RPH)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:O
Last Name:ADETULA
Suffix:
Gender:M
Credentials:PHD RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 E WHEATLAND ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75116
Mailing Address - Country:US
Mailing Address - Phone:972-572-1939
Mailing Address - Fax:972-572-9990
Practice Address - Street 1:777 E WHEATLAND ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116
Practice Address - Country:US
Practice Address - Phone:972-572-1939
Practice Address - Fax:972-572-9990
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19614183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1245160Medicaid
1313330001Medicare ID - Type Unspecified
LA1245160Medicaid