Provider Demographics
NPI:1174286686
Name:AJAO, ANTHONIA (PHARMD)
Entity type:Individual
Prefix:
First Name:ANTHONIA
Middle Name:
Last Name:AJAO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-5337
Mailing Address - Country:US
Mailing Address - Phone:973-943-6517
Mailing Address - Fax:
Practice Address - Street 1:2707 GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-5337
Practice Address - Country:US
Practice Address - Phone:973-943-6517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1051572183500000X
NJ28RI02873500183500000X
AZS023897183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist