Provider Demographics
NPI:1730688771
Name:BOLDEN, GEVONI (PHARMD)
Entity type:Individual
Prefix:
First Name:GEVONI
Middle Name:
Last Name:BOLDEN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2041 BETTY BLVD
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-4613
Mailing Address - Country:US
Mailing Address - Phone:504-812-9259
Mailing Address - Fax:
Practice Address - Street 1:1619 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-3609
Practice Address - Country:US
Practice Address - Phone:601-684-8670
Practice Address - Fax:601-684-3465
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.0191653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy