Provider Demographics
NPI:1700234473
Name:LONGE, OLUKAYODE
Entity Type:Individual
Prefix:
First Name:OLUKAYODE
Middle Name:
Last Name:LONGE
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 1:805 JOLIET ST
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311
Mailing Address - Country:US
Mailing Address - Phone:219-864-4314
Mailing Address - Fax:219-864-9286
Practice Address - Street 1:805 JOLIET ST
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-1920
Practice Address - Country:US
Practice Address - Phone:219-864-4314
Practice Address - Fax:219-864-9286
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26092004A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist