Provider Demographics
NPI:1073624714
Name:AJIBOLA A SADIQR
Entity Type:Organization
Organization Name:AJIBOLA A SADIQR
Other - Org Name:COOPER MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:AJIBOLA
Authorized Official - Middle Name:A
Authorized Official - Last Name:SADIQR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-888-0724
Mailing Address - Street 1:7210 REMMET AVE
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303-1531
Mailing Address - Country:US
Mailing Address - Phone:818-888-0724
Mailing Address - Fax:818-888-9021
Practice Address - Street 1:7210 REMMET AVE
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-1531
Practice Address - Country:US
Practice Address - Phone:818-888-0724
Practice Address - Fax:818-888-9021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47081332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5037130001Medicare ID - Type UnspecifiedPROVIDER