Provider Demographics
NPI:1073125845
Name:OKPOGIE, AISOSA DEBORAH (PHARMD)
Entity Type:Individual
Prefix:
First Name:AISOSA
Middle Name:DEBORAH
Last Name:OKPOGIE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 RUSSELL DR
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60192-4583
Mailing Address - Country:US
Mailing Address - Phone:510-589-8650
Mailing Address - Fax:
Practice Address - Street 1:11 E 75TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-1601
Practice Address - Country:US
Practice Address - Phone:773-224-1211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0513000413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL314228594Medicaid