Provider Demographics
NPI:1427413160
Name:OGBALIDET, HAILE
Entity Type:Individual
Prefix:
First Name:HAILE
Middle Name:
Last Name:OGBALIDET
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 1:14088 KAHLER PL
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80023-4546
Mailing Address - Country:US
Mailing Address - Phone:303-659-9660
Mailing Address - Fax:303-637-9022
Practice Address - Street 1:1605 E. BRIDGE ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601
Practice Address - Country:US
Practice Address - Phone:303-659-9660
Practice Address - Fax:303-637-9022
Is Sole Proprietor?:No
Enumeration Date:2015-12-23
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16260183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist