Provider Demographics
NPI:1316586969
Name:BOLANLE, OLUGBADE (RPH, MBA)
Entity type:Individual
Prefix:
First Name:OLUGBADE
Middle Name:
Last Name:BOLANLE
Suffix:
Gender:M
Credentials:RPH, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16060 EUREKA RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-3458
Mailing Address - Country:US
Mailing Address - Phone:734-785-8315
Mailing Address - Fax:734-785-8251
Practice Address - Street 1:16060 EUREKA RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-3458
Practice Address - Country:US
Practice Address - Phone:734-785-8315
Practice Address - Fax:734-785-8251
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302034074183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist