Provider Demographics
NPI:1326628835
Name:BOGLISCH, PHILLIP (PHARMD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:BOGLISCH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 FRESHWATER BLVD
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-3854
Mailing Address - Country:US
Mailing Address - Phone:860-394-2028
Mailing Address - Fax:860-394-2028
Practice Address - Street 1:75 FRESHWATER BLVD
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3854
Practice Address - Country:US
Practice Address - Phone:860-394-2028
Practice Address - Fax:860-394-2025
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPCT.0013915183500000X
CTPH236708183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist