Provider Demographics
NPI:1346535994
Name:BLOODGOOD, LAURA JEAN
Entity Type:Individual
Prefix:MR
First Name:LAURA
Middle Name:JEAN
Last Name:BLOODGOOD
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 1:1188 W BOUGHTON RD
Mailing Address - Street 2:T-0867
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1508
Mailing Address - Country:US
Mailing Address - Phone:630-378-1011
Mailing Address - Fax:
Practice Address - Street 1:1188 W BOUGHTON RD
Practice Address - Street 2:T-0867
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1508
Practice Address - Country:US
Practice Address - Phone:630-378-1011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-12
Last Update Date:2011-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051286239183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist