Provider Demographics
NPI:1770863409
Name:FOGELSONGER, JACK L (RPH)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:L
Last Name:FOGELSONGER
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 1:909 SHOAL CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-9414
Mailing Address - Country:US
Mailing Address - Phone:757-410-7775
Mailing Address - Fax:
Practice Address - Street 1:1316 BATTLEFIELD BLVD N
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4517
Practice Address - Country:US
Practice Address - Phone:757-548-4217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202001613183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist