Provider Demographics
NPI:1508149196
Name:SIJUWADE, BO
Entity Type:Individual
Prefix:
First Name:BO
Middle Name:
Last Name:SIJUWADE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 381172
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75138-1172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8113 RIDGEPOINT DR
Practice Address - Street 2:SUITE 200
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-3197
Practice Address - Country:US
Practice Address - Phone:972-556-1623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX49259183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist