Provider Demographics
NPI:1114581014
Name:VOGT, MARK A
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:VOGT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 E 22ND ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-2608
Mailing Address - Country:US
Mailing Address - Phone:402-578-9734
Mailing Address - Fax:402-721-2288
Practice Address - Street 1:526 N LINDEN ST
Practice Address - Street 2:
Practice Address - City:WAHOO
Practice Address - State:NE
Practice Address - Zip Code:68066-1961
Practice Address - Country:US
Practice Address - Phone:402-443-4167
Practice Address - Fax:402-443-4168
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10739183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist