Provider Demographics
NPI:1669647079
Name:LAWAL, MODINAT ADENIKE (RPH)
Entity type:Individual
Prefix:
First Name:MODINAT
Middle Name:ADENIKE
Last Name:LAWAL
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 1:1149 SUNRISE HWY
Mailing Address - Street 2:TARGET PHARMACY T-1147
Mailing Address - City:COPIAGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11726-1330
Mailing Address - Country:US
Mailing Address - Phone:631-841-5067
Mailing Address - Fax:631-841-5067
Practice Address - Street 1:1149 SUNRISE HWY
Practice Address - Street 2:TARGET PHARMACY T-1147
Practice Address - City:COPIAGUE
Practice Address - State:NY
Practice Address - Zip Code:11726-1330
Practice Address - Country:US
Practice Address - Phone:631-841-5067
Practice Address - Fax:631-841-5067
Is Sole Proprietor?:No
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046364183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist