Provider Demographics
NPI:1902670250
Name:OGUNBODE, ABIDEMI OLUWASEUN
Entity Type:Individual
Prefix:
First Name:ABIDEMI
Middle Name:OLUWASEUN
Last Name:OGUNBODE
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 1:6084 S GORDON RD
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30168-4944
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:590 THORNTON RD
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-1574
Practice Address - Country:US
Practice Address - Phone:678-945-1640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH034620183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist