Provider Demographics
NPI:1104362086
Name:FOGEL, LEORA (PHARMD)
Entity Type:Individual
Prefix:
First Name:LEORA
Middle Name:
Last Name:FOGEL
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 1:24 TESORO
Mailing Address - Street 2:
Mailing Address - City:NEWPORT COAST
Mailing Address - State:CA
Mailing Address - Zip Code:92657-1215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 TESORO
Practice Address - Street 2:
Practice Address - City:NEWPORT COAST
Practice Address - State:CA
Practice Address - Zip Code:92657-1215
Practice Address - Country:US
Practice Address - Phone:949-712-0302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-16
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH444501835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist