Provider Demographics
NPI:1366740508
Name:OLUDARE, BUKOLA (B PHARM)
Entity type:Individual
Prefix:MS
First Name:BUKOLA
Middle Name:
Last Name:OLUDARE
Suffix:
Gender:F
Credentials:B PHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4694 FORSYTH RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-4420
Mailing Address - Country:US
Mailing Address - Phone:478-474-3077
Mailing Address - Fax:478-474-1759
Practice Address - Street 1:4694 FORSYTH RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4420
Practice Address - Country:US
Practice Address - Phone:478-474-3077
Practice Address - Fax:478-474-1759
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-12
Last Update Date:2011-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023077183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist