Provider Demographics
NPI:1982715447
Name:GBOGBARA INC
Entity Type:Organization
Organization Name:GBOGBARA INC
Other - Org Name:KING PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LENYIE
Authorized Official - Middle Name:N
Authorized Official - Last Name:NGBOGBARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-331-8484
Mailing Address - Street 1:12871 E JEFFERSON
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-2754
Mailing Address - Country:US
Mailing Address - Phone:313-331-8484
Mailing Address - Fax:313-331-1864
Practice Address - Street 1:12871 E JEFFERSON
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2754
Practice Address - Country:US
Practice Address - Phone:313-331-8484
Practice Address - Fax:313-331-1864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010062763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3155302Medicaid
MI4722250001Medicare PIN
MI3155302Medicaid