Provider Demographics
NPI:1407003429
Name:FOGEL, MARK G (RPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:FOGEL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2985 BRENTWOOD CT
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-4522
Mailing Address - Country:US
Mailing Address - Phone:516-409-2189
Mailing Address - Fax:
Practice Address - Street 1:170 W PARK AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-3317
Practice Address - Country:US
Practice Address - Phone:516-431-0611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035387183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist