Provider Demographics
NPI:1235737792
Name:OBENG, MIKE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:OBENG
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 1:5725 CHENSFORD DR APT 2C
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46226-1251
Mailing Address - Country:US
Mailing Address - Phone:574-383-9206
Mailing Address - Fax:
Practice Address - Street 1:5960 CASTLEWAY WEST DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-1977
Practice Address - Country:US
Practice Address - Phone:574-383-9206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26027298A3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy