Provider Demographics
NPI:1265565048
Name:AGBEDE, BOLAJI A (RPH)
Entity type:Individual
Prefix:MR
First Name:BOLAJI
Middle Name:A
Last Name:AGBEDE
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 1:1342 FLAXWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-8809
Mailing Address - Country:US
Mailing Address - Phone:813-685-3209
Mailing Address - Fax:813-657-2449
Practice Address - Street 1:179 E BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-8102
Practice Address - Country:US
Practice Address - Phone:813-681-9858
Practice Address - Fax:813-661-3602
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS0034678183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0556050097Medicare ID - Type Unspecified