Provider Demographics
NPI:1225637929
Name:BOGUCKI, JESSICA LYNN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:BOGUCKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13620 HIGHWAY 43 N
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35475-4580
Mailing Address - Country:US
Mailing Address - Phone:205-333-0678
Mailing Address - Fax:205-333-0924
Practice Address - Street 1:5324 BRISTOLWOOD CIR
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35475-5938
Practice Address - Country:US
Practice Address - Phone:205-792-7494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15563183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist