Provider Demographics
NPI:1104426329
Name:BOGGS, JULIE WUNDERLIN
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:WUNDERLIN
Last Name:BOGGS
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 1:1524 HIGHWAY 16 W
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-2046
Mailing Address - Country:US
Mailing Address - Phone:770-229-7427
Mailing Address - Fax:
Practice Address - Street 1:1524 HIGHWAY 16 W
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-2046
Practice Address - Country:US
Practice Address - Phone:770-229-7430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH0181741835P0018X
GA0181741835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist