Provider Demographics
NPI:1043659451
Name:MOGER, BONITA LYNNE (RPH)
Entity Type:Individual
Prefix:
First Name:BONITA
Middle Name:LYNNE
Last Name:MOGER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2026 S POKEGAMA AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-4288
Mailing Address - Country:US
Mailing Address - Phone:218-326-9431
Mailing Address - Fax:218-326-9433
Practice Address - Street 1:2026 S POKEGAMA AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-4288
Practice Address - Country:US
Practice Address - Phone:218-326-9431
Practice Address - Fax:218-326-9433
Is Sole Proprietor?:No
Enumeration Date:2013-06-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115670183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist