Provider Demographics
NPI:1619204005
Name:OGBOLU, ANTHONY IKEM (RPH)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:IKEM
Last Name:OGBOLU
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:ANTHONY
Other - Middle Name:IKEM
Other - Last Name:OGBOLU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1520 PIONEER RD
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-6033
Mailing Address - Country:US
Mailing Address - Phone:972-288-8287
Mailing Address - Fax:972-288-0839
Practice Address - Street 1:1520 PIONEER RD
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-6033
Practice Address - Country:US
Practice Address - Phone:972-288-8287
Practice Address - Fax:972-288-0839
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX46021183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist