Provider Demographics
NPI:1437267580
Name:BONGEY, GARY (RPH)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:BONGEY
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 1:405 MELODY LN
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-1431
Mailing Address - Country:US
Mailing Address - Phone:608-848-8020
Mailing Address - Fax:608-848-8024
Practice Address - Street 1:202 S MAIN ST
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593-1422
Practice Address - Country:US
Practice Address - Phone:608-848-8020
Practice Address - Fax:608-848-8024
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10104-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist