Healthcare Provider Details

I. General information

NPI: 1710334065
Provider Name (Legal Business Name): SODIQ OGUNNAIKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7530 S STONY ISLAND AVE
CHICAGO IL
60649-3914
US

IV. Provider business mailing address

7530 S STONY ISLAND AVE
CHICAGO IL
60649-3914
US

V. Phone/Fax

Practice location:
  • Phone: 773-288-7002
  • Fax:
Mailing address:
  • Phone: 773-288-7002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051298338
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: