Healthcare Provider Details

I. General information

NPI: 1427413160
Provider Name (Legal Business Name): HAILE OGBALIDET
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2015
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 E. BRIDGE ST
BRIGHTON CO
80601
US

IV. Provider business mailing address

14088 KAHLER PL
BROOMFIELD CO
80023-4546
US

V. Phone/Fax

Practice location:
  • Phone: 303-659-9660
  • Fax: 303-637-9022
Mailing address:
  • Phone: 303-659-9660
  • Fax: 303-637-9022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number16260
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: