Provider Demographics
NPI:1538989439
Name:OMOLE, OLUWASEUN
Entity type:Individual
Prefix:
First Name:OLUWASEUN
Middle Name:
Last Name:OMOLE
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 1:177 MEADOWBROOK LN
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:19015-2812
Mailing Address - Country:US
Mailing Address - Phone:610-653-4478
Mailing Address - Fax:
Practice Address - Street 1:410 E CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:RIDLEY PARK
Practice Address - State:PA
Practice Address - Zip Code:19078-1808
Practice Address - Country:US
Practice Address - Phone:610-532-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP458971183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist