Provider Demographics
NPI:1306386826
Name:GOGOLIN, SEAN (RPH)
Entity type:Individual
Prefix:MR
First Name:SEAN
Middle Name:
Last Name:GOGOLIN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7492 JERICHO AVE NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-8697
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4575 44TH ST SE
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-4080
Practice Address - Country:US
Practice Address - Phone:866-618-5695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028325183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist