Provider Demographics
NPI:1578604104
Name:ROGERS, BRUCE WILSON (RPH)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:WILSON
Last Name:ROGERS
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 1:4404 N LAURENT ST
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-2742
Mailing Address - Country:US
Mailing Address - Phone:361-576-6599
Mailing Address - Fax:361-894-6431
Practice Address - Street 1:4404 N LAURENT ST
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-2742
Practice Address - Country:US
Practice Address - Phone:361-576-6599
Practice Address - Fax:361-894-6431
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX332B00000X
TX21067183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX21067OtherSTATE BOARD OF PHARMACY
TX21067OtherSTATE BOARD OF PHARMACY