Provider Demographics
NPI:1851668974
Name:OGUNDIPE, BUSOLA OYEBIMPE
Entity Type:Individual
Prefix:
First Name:BUSOLA
Middle Name:OYEBIMPE
Last Name:OGUNDIPE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 WILLIAM DR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-8182
Mailing Address - Country:US
Mailing Address - Phone:219-707-5615
Mailing Address - Fax:219-707-5619
Practice Address - Street 1:8001 BROADWAY STE 202
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5546
Practice Address - Country:US
Practice Address - Phone:219-736-8105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26021081A1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100307990Medicaid