Provider Demographics
NPI:1649820101
Name:BANDELE, IBUKUN OLADELE
Entity type:Individual
Prefix:
First Name:IBUKUN
Middle Name:OLADELE
Last Name:BANDELE
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 1:4968 WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90022-3130
Mailing Address - Country:US
Mailing Address - Phone:310-302-7800
Mailing Address - Fax:323-685-2840
Practice Address - Street 1:4968 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-3130
Practice Address - Country:US
Practice Address - Phone:310-302-7800
Practice Address - Fax:323-685-2840
Is Sole Proprietor?:No
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47055183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist