Provider Demographics
NPI:1881943793
Name:OGUNSUSI, RAPHAEL TAIWO (PHARMACIST)
Entity type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:TAIWO
Last Name:OGUNSUSI
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 WELLINGTON WAY SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-6413
Mailing Address - Country:US
Mailing Address - Phone:678-478-9511
Mailing Address - Fax:
Practice Address - Street 1:2630 WELLINGTON WAY SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-6413
Practice Address - Country:US
Practice Address - Phone:678-478-9511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA13344183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist