Provider Demographics
NPI:1376952192
Name:BOGARD, ELISE
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:BOGARD
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 1:6480 OLD WATERLOO RD
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075
Mailing Address - Country:US
Mailing Address - Phone:410-799-0291
Mailing Address - Fax:410-799-2589
Practice Address - Street 1:6480 OLD WATERLOO RD
Practice Address - Street 2:
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075
Practice Address - Country:US
Practice Address - Phone:410-799-0291
Practice Address - Fax:410-799-2589
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19582183500000X
NJ28RI03210400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist