Provider Demographics
NPI:1891096517
Name:BOLOG, LEONARD (RPH)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:
Last Name:BOLOG
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 1:595 E PARKS HWY # 300
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8102
Mailing Address - Country:US
Mailing Address - Phone:907-352-1160
Mailing Address - Fax:
Practice Address - Street 1:595 E PARKS HWY # 300
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8102
Practice Address - Country:US
Practice Address - Phone:907-352-1160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-11
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1705183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist