Provider Demographics
NPI:1669140273
Name:BRUGGEMAN, ANDREA MARIE
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARIE
Last Name:BRUGGEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12321 WATERSTONE LN APT 203
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-3018
Mailing Address - Country:US
Mailing Address - Phone:937-776-9167
Mailing Address - Fax:
Practice Address - Street 1:5224 DORR ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-3602
Practice Address - Country:US
Practice Address - Phone:419-531-2115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03441124183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist