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	5301006276	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982715447
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GBOGBARA INC

Provider Business Mailing Address
First Line	:	12871 E JEFFERSON
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48215-2754
Country	:	US
Telephone Number	:	313-331-8484
Fax Number	:	313-331-1864

Provider Business Practice Location Address
First Line	:	12871 E JEFFERSON
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48215-2754
Country	:	US
Telephone Number	:	313-331-8484
Fax Number	:	313-331-1864

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	12/09/2020

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Directions to “GBOGBARA INC ” Practice Location

Language	Start Address	Practice Location

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