Provider Demographics
NPI:1134300668
Name:BOGNER, LISA M (RPH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:BOGNER
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 1:1405 GLIDDEN CIR
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:NY
Mailing Address - Zip Code:14047-9680
Mailing Address - Country:US
Mailing Address - Phone:716-947-9676
Mailing Address - Fax:
Practice Address - Street 1:3590 UNION RD
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14047
Practice Address - Country:US
Practice Address - Phone:716-634-3603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047535183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist