Provider Demographics
NPI:1083255988
Name:ADESHOLA, OLUSEGUN I (PHARMD)
Entity Type:Individual
Prefix:
First Name:OLUSEGUN
Middle Name:I
Last Name:ADESHOLA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10343 S INDIANA AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-2818
Mailing Address - Country:US
Mailing Address - Phone:817-707-2392
Mailing Address - Fax:
Practice Address - Street 1:1050 W ARKANSAS LN
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76013-6308
Practice Address - Country:US
Practice Address - Phone:817-702-6313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.302613183500000X
TX64774183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051.302613OtherPHARMACIST LICENSE