Provider Demographics
NPI:1376660993
Name:OLAJIDE, GBENGA ISAAC (RPH)
Entity Type:Individual
Prefix:MR
First Name:GBENGA
Middle Name:ISAAC
Last Name:OLAJIDE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:GBENGA
Other - Middle Name:ISAAC
Other - Last Name:OLAJIDE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5901 NORWAY CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-5732
Mailing Address - Country:US
Mailing Address - Phone:410-566-1360
Mailing Address - Fax:410-566-5088
Practice Address - Street 1:2021 W PRATT ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21223-2242
Practice Address - Country:US
Practice Address - Phone:410-566-1360
Practice Address - Fax:410-566-5088
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13190183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD13190OtherBOARD LICENCE