Provider Demographics
NPI:1780048363
Name:SIDAROUS, BOLA (RPH)
Entity type:Individual
Prefix:
First Name:BOLA
Middle Name:
Last Name:SIDAROUS
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 1:901 JOHN BARROW RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6503
Mailing Address - Country:US
Mailing Address - Phone:717-319-4033
Mailing Address - Fax:501-604-8009
Practice Address - Street 1:901 JOHN BARROW RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6503
Practice Address - Country:US
Practice Address - Phone:717-319-4033
Practice Address - Fax:501-604-8009
Is Sole Proprietor?:No
Enumeration Date:2016-04-08
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72008183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist