Provider Demographics
NPI:1487371019
Name:BRUGGEMAN, EVAN
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:BRUGGEMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5207 FORT RECOVERY MINSTER RD
Mailing Address - Street 2:
Mailing Address - City:SAINT HENRY
Mailing Address - State:OH
Mailing Address - Zip Code:45883-9738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:943 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:IN
Practice Address - Zip Code:47394-9294
Practice Address - Country:US
Practice Address - Phone:765-584-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26030051A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist