=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134624554
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OLA BIDEX OGUNDIYA PHARMD, RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2018
-----------------------------------------------------
Last Update Date | 04/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3555 GREENWOOD RD
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-525-0144
-----------------------------------------------------
Fax | 318-525-0222
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1733 S REUNION DR
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71118-2250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-708-2305
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PST.022417
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------