Provider Demographics
NPI:1528775004
Name:AGBAERE, ABIMBOLA OLAYEMI
Entity type:Individual
Prefix:DR
First Name:ABIMBOLA
Middle Name:OLAYEMI
Last Name:AGBAERE
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:ABIMBOLA
Other - Middle Name:
Other - Last Name:ADEMOLA-DADA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:200 TECHNOLOGY CT SE STE B
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-5201
Mailing Address - Country:US
Mailing Address - Phone:678-981-7661
Mailing Address - Fax:
Practice Address - Street 1:200 TECHNOLOGY CT SE STE B
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-5201
Practice Address - Country:US
Practice Address - Phone:678-981-7661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX704061835P0018X
GARPH0297301835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist