Provider Demographics
NPI:1043543952
Name:ISHOLA, LOLA LAWAL
Entity type:Individual
Prefix:
First Name:LOLA
Middle Name:LAWAL
Last Name:ISHOLA
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 1:2117 VERMILLION CURV
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-6225
Mailing Address - Country:US
Mailing Address - Phone:651-503-7419
Mailing Address - Fax:
Practice Address - Street 1:2564 7TH AVE E
Practice Address - Street 2:
Practice Address - City:NORTH SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109-3010
Practice Address - Country:US
Practice Address - Phone:651-770-6606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-09
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
343900000X
MN115449183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1801126214Medicaid
MN1801126214Medicaid