Provider Demographics
NPI:1063860484
Name:GBOGBARA INC
Entity Type:Organization
Organization Name:GBOGBARA INC
Other - Org Name:KING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LENYIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NGBOGBARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-319-4444
Mailing Address - Street 1:28350 GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066
Mailing Address - Country:US
Mailing Address - Phone:586-218-8181
Mailing Address - Fax:586-884-3488
Practice Address - Street 1:28350 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066
Practice Address - Country:US
Practice Address - Phone:586-218-8181
Practice Address - Fax:586-884-3488
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GBOGBARA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-26
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010109453336C0003X, 3336C0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2160295OtherPK