Provider Demographics
NPI:1700142700
Name:SORINMADE, TOLULOPE
Entity Type:Individual
Prefix:
First Name:TOLULOPE
Middle Name:
Last Name:SORINMADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TOLULOPE
Other - Middle Name:
Other - Last Name:OLUBUNMI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:200 COVENTRY CIR
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 COVENTRY CIR
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1900
Practice Address - Country:US
Practice Address - Phone:703-945-3470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH24704183500000X
DCPH100000983183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist