Basic Information
| Provider Information | |||||||||
| NPI: | 1275080848 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FASANMI | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | AYOTOLA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARM D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11606 BRIGIT CT | ||||||||
| Address2: | |||||||||
| City: | BOWIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207204486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024418307 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9420 LANHAM SERVERN RD | ||||||||
| Address2: | |||||||||
| City: | LANHAM | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015775555 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2016 | ||||||||
| LastUpdateDate: | 09/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 24409 | MD | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.