Provider Demographics
NPI:1316286966
Name:MOGENSEN, MARK DANIEL (RPH)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DANIEL
Last Name:MOGENSEN
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 1:1015 13TH ST
Mailing Address - Street 2:
Mailing Address - City:MENOMINEE
Mailing Address - State:MI
Mailing Address - Zip Code:49858-2722
Mailing Address - Country:US
Mailing Address - Phone:906-863-2589
Mailing Address - Fax:
Practice Address - Street 1:1015 13TH ST
Practice Address - Street 2:
Practice Address - City:MENOMINEE
Practice Address - State:MI
Practice Address - Zip Code:49858-2722
Practice Address - Country:US
Practice Address - Phone:906-863-2589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-01
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11976-040183500000X
MI5302041718183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302041718OtherMICHIGAN PHARMACIST LICENSE
WI11976-040OtherWISCONSIN PHARMACIST LICENSE