Provider Demographics
NPI:1700559598
Name:ADEYEMO, OMISHOLA
Entity Type:Individual
Prefix:
First Name:OMISHOLA
Middle Name:
Last Name:ADEYEMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 301
Mailing Address - Street 2:
Mailing Address - City:REDAN
Mailing Address - State:GA
Mailing Address - Zip Code:30074-0301
Mailing Address - Country:US
Mailing Address - Phone:770-837-9034
Mailing Address - Fax:
Practice Address - Street 1:2415 DEKALB MEDICAL PKWY STE B
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4929
Practice Address - Country:US
Practice Address - Phone:770-837-9034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH018481183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist