Provider Demographics
NPI:1598048555
Name:OVIAWE-OSAGIE, IYOBOSA
Entity Type:Individual
Prefix:
First Name:IYOBOSA
Middle Name:
Last Name:OVIAWE-OSAGIE
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 1:11539 REAGAN DR
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-5303
Mailing Address - Country:US
Mailing Address - Phone:773-655-8310
Mailing Address - Fax:
Practice Address - Street 1:1530 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2307
Practice Address - Country:US
Practice Address - Phone:317-261-1753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26023788A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist