Provider Demographics
NPI:1164018933
Name:IKPONMWOSA, OSAYI (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:OSAYI
Middle Name:
Last Name:IKPONMWOSA
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 1:18213 HUMMINGBIRD DR
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-9535
Mailing Address - Country:US
Mailing Address - Phone:708-979-0044
Mailing Address - Fax:
Practice Address - Street 1:3405 RIDGE RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-2049
Practice Address - Country:US
Practice Address - Phone:219-972-7131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26025833A1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist