Provider Demographics
NPI:1619409844
Name:OBAITAN, BAMIDELE (RPH, CONSPH)
Entity type:Individual
Prefix:
First Name:BAMIDELE
Middle Name:
Last Name:OBAITAN
Suffix:
Gender:M
Credentials:RPH, CONSPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:558 FENWAY PLACE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806
Mailing Address - Country:US
Mailing Address - Phone:727-641-6221
Mailing Address - Fax:
Practice Address - Street 1:558 FENWAY PL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-4714
Practice Address - Country:US
Practice Address - Phone:727-641-6221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL38674183500000X
FL70091835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist