MEDICARE: GBOGBARA INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1609471135
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GBOGBARA INC

Provider Business Mailing Address
First Line	:	6202 GOLDEN LN
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322-3271
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	15200 GRATIOT AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48205-1327
Country	:	US
Telephone Number	:	313-821-4449
Fax Number	:	313-332-0317

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. LENYIE NGBOGBARA
Credential	:	RPH
Telephone Number	:	313-331-8484

Provider Enumeration Date	:	12/02/2020
Last Update Date	:	01/20/2021

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Directions to “GBOGBARA INC ” Practice Location

Language	Start Address	Practice Location

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