Provider Demographics
NPI:1295488674
Name:BOGUE, JUSTINE (PHARMD)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:BOGUE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 E COURT ST
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:IL
Mailing Address - Zip Code:61944-2478
Mailing Address - Country:US
Mailing Address - Phone:217-465-4114
Mailing Address - Fax:217-463-5801
Practice Address - Street 1:719 E COURT ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:IL
Practice Address - Zip Code:61944-2478
Practice Address - Country:US
Practice Address - Phone:217-465-4114
Practice Address - Fax:217-463-5801
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.295424183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist