Provider Demographics
NPI:1821122482
Name:SHOBOLA, KENNETH O (R PH)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:O
Last Name:SHOBOLA
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15779
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33684-5779
Mailing Address - Country:US
Mailing Address - Phone:813-426-5419
Mailing Address - Fax:
Practice Address - Street 1:4730 N HABANA AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7163
Practice Address - Country:US
Practice Address - Phone:813-348-0095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 29682183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS29682OtherBOARD OF PHARMACY