Provider Demographics
NPI:1326300930
Name:BAGDON, LEROY (RPH)
Entity Type:Individual
Prefix:
First Name:LEROY
Middle Name:
Last Name:BAGDON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3044
Mailing Address - Country:US
Mailing Address - Phone:425-259-6262
Mailing Address - Fax:
Practice Address - Street 1:2615 BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3044
Practice Address - Country:US
Practice Address - Phone:425-259-6262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-10
Last Update Date:2012-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH000100761835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric