Healthcare Provider Details

I. General information

NPI: 1851668974
Provider Name (Legal Business Name): BUSOLA OYEBIMPE OGUNDIPE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2011
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8001 BROADWAY STE 202
MERRILLVILLE IN
46410-5546
US

IV. Provider business mailing address

2610 WILLIAM DR
VALPARAISO IN
46385-8182
US

V. Phone/Fax

Practice location:
  • Phone: 219-736-8105
  • Fax:
Mailing address:
  • Phone: 219-707-5615
  • Fax: 219-707-5619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number26021081A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: