Provider Demographics
NPI:1831841121
Name:BOGUN, VALENTIN (PHARMD)
Entity type:Individual
Prefix:
First Name:VALENTIN
Middle Name:
Last Name:BOGUN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 W PIKE ST
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-2362
Mailing Address - Country:US
Mailing Address - Phone:574-534-7616
Mailing Address - Fax:
Practice Address - Street 1:601 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-2055
Practice Address - Country:US
Practice Address - Phone:260-637-6115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-19
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INCV2102887183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist