Provider Demographics
NPI:1760766141
Name:EZEOKOLI, BONIFACE IFEANYI
Entity Type:Individual
Prefix:MR
First Name:BONIFACE
Middle Name:IFEANYI
Last Name:EZEOKOLI
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 1:9475 E PICKWICK CIR
Mailing Address - Street 2:#28
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-3857
Mailing Address - Country:US
Mailing Address - Phone:313-334-3202
Mailing Address - Fax:
Practice Address - Street 1:9475 E PICKWICK CIR
Practice Address - Street 2:#28
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-3857
Practice Address - Country:US
Practice Address - Phone:313-334-3202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-04
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302036557183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist