Provider Demographics
NPI:1609904887
Name:FOGT, GREGORY W (RPH)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:W
Last Name:FOGT
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 1:11659 N TOWNSHIP ROAD 88
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:OH
Mailing Address - Zip Code:43331-9379
Mailing Address - Country:US
Mailing Address - Phone:937-843-5779
Mailing Address - Fax:
Practice Address - Street 1:120 W. MAIN ST.
Practice Address - Street 2:
Practice Address - City:RUSSELLS POINT
Practice Address - State:OH
Practice Address - Zip Code:43348-0636
Practice Address - Country:US
Practice Address - Phone:937-843-2048
Practice Address - Fax:937-843-2371
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-1-10786183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist