Provider Demographics
NPI:1508653692
Name:BOGANNAM, ALEXIS ROSE (PHARMD)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:ROSE
Last Name:BOGANNAM
Suffix:
Gender:
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-6242
Mailing Address - Country:US
Mailing Address - Phone:978-307-6307
Mailing Address - Fax:631-255-9141
Practice Address - Street 1:701 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-6242
Practice Address - Country:US
Practice Address - Phone:978-307-6307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-22
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH2411711835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist