Provider Demographics
NPI:1376121681
Name:FOGG, MARY CATHERINE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:FOGG
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 1:12509 RICHMOND ST
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-4446
Mailing Address - Country:US
Mailing Address - Phone:804-894-6749
Mailing Address - Fax:
Practice Address - Street 1:5700 HOPKINS RD
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23234-6631
Practice Address - Country:US
Practice Address - Phone:804-253-0759
Practice Address - Fax:804-253-9788
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0230015174183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician