Provider Demographics
NPI:1053991141
Name:DUAGBOR, ISHMAEL
Entity type:Individual
Prefix:
First Name:ISHMAEL
Middle Name:
Last Name:DUAGBOR
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 1:2351 SPRINGSIDE LN N APT C
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-6504
Mailing Address - Country:US
Mailing Address - Phone:775-441-0820
Mailing Address - Fax:
Practice Address - Street 1:7240 E 82ND ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1404
Practice Address - Country:US
Practice Address - Phone:317-849-8150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26029164A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty