Provider Demographics
NPI:1891017612
Name:BOLOGH, IRA (RPH)
Entity Type:Individual
Prefix:MR
First Name:IRA
Middle Name:
Last Name:BOLOGH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-7112
Mailing Address - Country:US
Mailing Address - Phone:201-339-1992
Mailing Address - Fax:201-858-1714
Practice Address - Street 1:455 BROADWAY
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-7112
Practice Address - Country:US
Practice Address - Phone:201-339-1992
Practice Address - Fax:201-858-1714
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-21
Last Update Date:2010-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01187100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist