Provider Demographics
NPI:1326648338
Name:BOURGOIN, RICARDO STEPHANN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:RICARDO
Middle Name:STEPHANN
Last Name:BOURGOIN
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 1:3699 LEAR CT
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-7745
Mailing Address - Country:US
Mailing Address - Phone:678-510-9570
Mailing Address - Fax:
Practice Address - Street 1:5448 WHITTLESEY BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-7295
Practice Address - Country:US
Practice Address - Phone:706-322-8950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS58805183500000X
NY067171-01183500000X
GARPH031163183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist