Healthcare Provider Details

I. General information

NPI: 1619409844
Provider Name (Legal Business Name): BAMIDELE OBAITAN R.PH., CONS.PH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

558 FENWAY PL
ORLANDO FL
32806-4714
US

IV. Provider business mailing address

558 FENWAY PLACE
ORLANDO FL
32806
US

V. Phone/Fax

Practice location:
  • Phone: 727-641-6221
  • Fax:
Mailing address:
  • Phone: 727-641-6221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number38674
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number7009
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: